Thursday 29th July, 2021

Trigger points and tennis elbow: cause, diagnosis and treatment

Tennis elbow

Tennis elbow is described as an overuse injury causing pain at the outside of your elbow, especially when gripping or bending your wrist backwards. (Myofascial) trigger points are a common but overlooked cause. They cause tennis elbow either directly by causing abnormal tension on the injured tissue, or indirectly by causing pain that mimics tennis elbow. Trigger points are very commonly found in those suffering from tennis elbow, and trigger point therapies are very helpful in relieving or eliminating tennis elbow.

In this article we look at what trigger points are and how they cause tennis elbow. We will cover simple tests you can do to see if you have tennis elbow caused by trigger points, then give you a strategy to help eliminate your tennis elbow.

CONTENTS

What is tennis elbow (lateral epicondylitis)
What are trigger points
What causes tennis elbow
How trigger points cause tennis elbow
The evidence
How is tennis elbow disagnosed (do you have tennis elbow)
Trigger points are often overlooked
Further problem: inadequate treatment of trigger points
Practical advice on tennis elbow prevention and treatment
Professionals
References

What is tennis elbow (lateral epicondylitis)

Tennis elbow is the irritation or injury to the outside of the elbow where many of your forearm muscles are attached. This attachment is called the lateral epicondyle, hence the technical name of lateral epicondylitis. The condition is common in tennis players, hence the name tennis elbow, but it can be caused by any repetitive activity involving forearms and gripping. It is even a common problem in those continually using a computer.

What are trigger points

Simply speaking, trigger points are those tight lumps in your muscles that therapists find. We cover these a lot more in our article Trigger point basics. They start as small lumps then slowly develop over time, and can eventually start referring pain, but even before then they cause the muscle they are in to abnormally tighten (1,2)⁠.

What causes tennis elbow

We’ll first give you the simple model of how tennis elbow forms that you’ll find in medical journals and most articles or videos, then give you the complete realistic version.

Basic medical model of tennis elbow

The cause of tennis elbow: the simple medical version

The simple explanation of tennis elbow is that repetitive activities create stress on the attachment of the muscles at the lateral epicondyle (outside of your elbow) causing irritation, leading to inflammation and injury. Tendons are slow to heal and there can be a buildup of scar tissue that causes further irritation, causing the condition to become entrenched (3–5)⁠.

The complete model of tennis elbow

The cause of tennis elbow: complete

As well as creating stress upon the attachment at the lateral epicondyle the repetitive activities cause muscles to tighten and develop trigger points, which further tighten the muscles. This tightness creates extra tension on the attachment at the lateral epicondyle. This creates the following important differences.

  • Instead of just repetitive activity causing stress you have repeated activity plus abnormal tension.
  • Trigger points can cause pain in their own right.

The difference it causes

The key is that under the simple medical model if you remove the stress from repeated activity (eg. rest or a brace) and the problem should go away. The reality is that trigger points don’t go away with rest so the abnormal tension remains, and the condition fails to heal. Even if the pain settles with rest, braces or medication, with the abnormal tension remaining it will quickly flare up again.

How trigger points cause tennis elbow

Directly

As discussed, trigger points can cause tennis elbow by causing abnormal tension in the forearm muscles that attach to the lateral epicondyle at the outside of the elbow.

Supinator muscle trigger point causing elbow pain
Example of a forearm muscle (Supinator) trigger point referring pain to the side of the elbow

Indirectly

Trigger points can refer pain to areas away from the actual trigger points. Many refer pain to the elbow region so they can mimic or add to the pain of a tennis elbow injury. In this case the same movements or activities that stress the injury at the outside of the elbow often also stress the trigger points. Therefore, the same activity can cause pain both directly and indirectly. Finally, pain from trigger points can sensitise the nervous system so any pain is amplified. This is discussed further in our article on fibromyalgia, but what it means is that even relatively minor pain signals from the elbow or trigger points are felt as being much worse and unrelenting.

The evidence that trigger points are a big cause of trigger points

There can be no question that trigger points are a big cause of tennis elbow. Scientists have established that activity causes them and that they cause muscles to tighten (1,2,6–8)⁠ , and tightness obviously causes stress. Further, several studies have shown that tennis elbow sufferers have large numbers of trigger points compared with non-sufferers (9–11)⁠, and trigger point therapy is shown to provide effective relief (3,12–14)⁠.

How is tennis elbow diagnosed (do you have tennis elbow)

Lets look at how tennis elbow is diagnosed. The tests are something simple you can do yourself, but please discuss them with a professional.

Symptoms of tennis elbow

The symptoms of tennis elbow are pain at the outside of your elbow, aggravated by activities such as bending back your wrist or fingers, or by gripping.

Simple tests for tennis elbow

There are two basic tests a doctor will do to diagnose tennis elbow.

Examining for tenderness

Examine the outside of your elbow. It will be very tender at the bony bump (lateral epicondyle) and for 1-2 cm towards your wrist (the tendon).

Provocation tests

There are a couple of tests with the impressive sounding names Mills and Cozens tests, but these are basically i) bending your wrist forward to tighten the muscles at the back of your forearm that attach to the lateral epicondyle, and ii) bending the wrist back the other way against resistance. These pull on the area injured in tennis elbow, so if they cause pain it is considered positive.

Tests for trigger point involvement

Simple palpation

This is simply examining your forearm muscles for trigger points. This can be done using the technique demonstrated in our video on forearm muscles. If you find trigger points they will certainly be causing the muscles to be tight, so they will be involved. If pressing on them causes your elbow pain it also shows that they are indirectly causing pain as well.

Tension relief test

This simply tests what happens if the tension caused by trigger points is temporarily removed.

Step one: Try gripping something or bending your wrist back against resistance to reproduce the pain, then examine the outside of your elbow for tenderness.

Step two: Temporarily relieve the tension in your forearm muscles by treating the trigger points using either of the two methods in our video

Step three: Re-test your elbow by doing the activity that previously caused pain and by examining the side of your elbow. If the activity is less painful or the tenderness at the side of your elbow is reduced it is a sign that tension due to trigger points is contributing to you tennis elbow

This cause of trigger points is too often overlooked

Despite the evidence to the contrary, including the fact that you can do simple tests yourself to confirm it, medicine tends to just consider their simple model. Medical journals typically ignore trigger points, and standard treatments typically just include rest, ice, non-steroidal anti-inflammatory drugs, corticosteroid injections, exercises and stretching (4,5)⁠. Consider what happens as a result.

  1. With rest and anti-inflammatory drugs pain may go away, but with the abnormal tension caused by trigger points the injury will not heal and pain will quickly return.
  2. As discussed in our article on trigger points muscles containing trigger points will not properly stretch. Therefore, the standard procedures of using stretching and strengthening exercises will not provide an effective long term solution, and likely aggravate the injury.
  3. As the result of this inappropriate treatment the condition will become chronic (nastier and more entrenched). The trigger points will continue to be ignored, and therapy will be directed at the injured tendon.

Further problem: inadequate treatment of trigger points

If the medical model wasn’t enough of a problem, when trigger points are identified their treatment is often temporary in nature. For further information on this please see our article Why trigger points keep coming back. As an example, if you go to Youtube there will be a large number of videos showing trigger point release techniques for tennis elbow. They may provide relief, but any effect of relaxing the muscle with trigger points will be temporary.

Practical advice on Tennis elbow prevention and treatment

The prevention of tennis elbow

The simple medical model

The simple medical model of tennis elbow only attributes repetitive activities to causing tennis elbow, so the standard prevention advise is to modify or eliminate those activities. However, this ignores the tension caused by trigger points in the forearm muscles.

The complete model

By acknowledging the effects of trigger points one can also help prevent trigger points by checking for and eliminating trigger points in the forearm muscles as well as modifying or eliminating the activities. Please see our video on massaging forearm muscles for two excellent techniques.

The treatment of tennis elbow

As discussed previously, treatment following the medical model ignores a major component, and is therefore deficient and inappropriate. We give the following advice to take this into account.

Minor tennis elbow issues

If your tennis elbow just involves minor intermittent pain it is likely that there is no serious damage or scar tissue affecting the tendon at the elbow, so use a trial of the forearm massage techniques as shown in our video. The condition will likely resolve, but if it doesn’t you’ll need to seek professional help.

More serious tennis elbow issues

If you have maintained your forearm muscles and taken care of minor issues this should never be a consideration, but if it is you will need to consult a professional for help. There are some considerations though.

  1. Removing abnormal tension from your forearm muscles will still be very important, so as well as any other forms of therapy you will probably still need to continue massaging your forearms.
  2. Interventions designed to help the tendon will work much faster and better if you have removed the abnormal tension from the forearm muscles.
  3. Exercises and stretches put tension on the damaged tension. Using stretches to relieve tennis elbow is like a double edged sword. It temporarily stretches the muscle, relieving tension, but in do so pulls on the injured tendon. It is far more effective and safe to use the massage techniques to relax the forearm muscles initioally, then use exercises and stretches for rehabilitation after the condition has settled down.
Professional at desk
Professionals: click image to find out more and possibly trial vibration massage

Professionals

One of the techniques demonstrated in the video is vibration massage using one of our DrGraeme massagers. These are excellent for professional or self use. If you are a professional and wish to know more about this therapy, or possibly get a sample massager to trial please check out our practitioner page.

References

  1. Shah J et al. Myofascial Trigger Points Then and Now: A Historical and Scientific Perspective. HHS Public Access. 2015;7(7):746–61.
  2. Celik D, Mutlu EK. Clinical implication of latent myofascial trigger point topical collection on myofascial pain. Curr Pain Headache Rep. 2013;17(8).
  3. Trivedi P, Sathiyavani D, Nambi G, Khuman R, Shah K, Bhatt P. Comparison of active release technique and myofascial release technique on pain, grip strength & functional performance in patients with chronic lateral epicondylitis. Int J Physiother Res. 2014;2(3):488–94.
  4. Smidt N, Windt DAWM Van Der, Assendelft WJJ, Devillé WLJM, Bos IBCK. Corticosteroid injections , physiotherapy , or a wait-and-see policy for lateral epicondylitis : a randomised controlled trial. Lancet. 2002;359:657–62.
  5. Johnson GW, Cadwallader K, Scheffel SB, Epperly TEDD. Treatment of Lateral Epicondylitis. Am Fam Physician. 2007;(76):843–50.
  6. Jafri MS. Mechanisms of Myofascial Pain. Int Sch Res Not. 2014;2014:1–16.
  7. Zhuang XQ, Tan SS, Huang QM. Understanding of myofascial trigger points. Chin Med J (Engl). 2014;127(24):4271–7.
  8. Bron C, Dommerholt JD. Etiology of myofascial trigger points. Curr Pain Headache Rep. 2012;16(5):439–44.
  9. Fernández-Carnero J, Fernández-De-Las-Peñas C, De La Llave-Rincón AI, Ge HY, Arendt-Nielsen L, Johnson GW, et al. Prevalence of and referred pain from myofascial trigger points in the forearm muscles in patients with lateral epicondylalgia. Clin J Pain . 2007;23(4):353–60.
  10. Aggarwal A, Daniel J, Palekar TJ. Prevalence of Myofascial Trigger Points in Brachioradialis, Biceps Brachii, Triceps Brachii, Supinator and Extensor Carpi Radialis Brevis in Lateral Epicondylitis. Indian J Physiother Occup Ther - An Int J. 2020;(1):14–8.
  11. Fernández-Carnero J, Fernández-De-Las-Peñas C, De La Llave-Rincón AI, Ge HY, Arendt-Nielsen L. Bilateral myofascial trigger points in the forearm muscles in patients with chronic unilateral lateral epicondylalgia: A blinded, controlled study. Clin J Pain. 2008;
  12. kotteeswaran k. EFFECT OF MYOFASCIAL TRIGGER POINT RELEASE THERAPY AND ACTIVE STRETCHING ON PAIN AMONG LATERAL EPICONDYLITIS PARTICIPANTS. Int J Res Anal Rev. 2019;6(2):184–8.
  13. Khuman R. Myofascial release technique in chronic lateral epicondylitis: a randomised controlled study. Int J Heal Sci Res. 2013;3(7):45–52.
  14. Ajimsha M. Effectiveness of myofasial release for lateral epicondylitis in computer professionals. Arch Phys Med Rehabil. 2012;93(4):604–9.

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Dr Graeme

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



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