A Review of Tennis Elbow
Rehabilitate The Whole Person, Not Just Injured Tissues
The presentation of pain in a tendon, does not always mean that the tendon is the primary contributor to pain. There research that suggests that a majority of nerves are found outside in peritendinous tissue, which is likely contributes to the complex clinical picture of tendon pain.
This is why clinicians should be thoughtful and skilled in managing the load on the tendons and supporting structures through a number of rehabilitation considerations including, but are not limited to:
• Manual Therapy (nerve mobilization, soft tissue massage, triggerpoint, IASTM)
• Education on psychosocial factors such as fear avoidance
• Loading Programs (eg. concentric, eccentric, isometric)
Why Does Massage Therapy Work for Elbow Pain?
A biopsychosocial framework helps put into context the interconnected and multidirectional interaction between: physiology, thoughts, emotions, behaviors, culture, and beliefs. In terms of clinical responses to massage therapy there are a couple of proposed mechanisms of action, including but not limited to: neurodynamics, contextually aided recovery, neuromodulation, social grooming and mechanotherapy.
Structures to be Aware of When Treating Elbow Pain
A massage therapy treatment plan should be implemented based on patient-specific assessment findings and patient tolerance. There may be times that focal irritability (ie. nerve irritation, triggerpoints, nervous system sensitization) co-exists with common extensor tendinopathy.
Massage therapists are uniquely suited to incorporate a number of rehabilitation strategies for patients with Elbow Pain. Structures to keep in mind while assessing and treating patients suffering from elbow pain may include neurovascular structures and investing fascia of:
• scalene muscles
• pectoralis minor
• biceps brachii muscle
• bicipital aponeurosis
• anterior interosseous membrane
• common extensor tendon (extensor carpi radialis brevis, extensor digitorum, extensor digiti minimi, extensor carpi ulnaris)
• common flexor tendon (pronator teres, flexor carpi radialis, palmaris longus, flexor digitorum superficialis, flexor carpi ulnaris)
More to Explore
Blanchette, M.A., Normand, M.C. (2011). Augmented soft tissue mobilization vs natural history in the treatment of lateral epicondylitis: a pilot study. J Manipulative Physiol Ther.
Campbell, D., Campbell, R., O'Connor, P., Hawkes, R. (2013). Sports-related extensor carpi ulnaris pathology: a review of functional anatomy, sports injury and management. Br J Sports Med. (OPEN ACCESS)
Cook, J. L., Rio, E., Purdam, C. R., & Docking, S. I. (2016). Revisiting the continuum model of tendon pathology: What is its merit in clinical practice and research? British Journal of Sports Medicine.
Cook, J., & Docking, S. (2015). “Rehabilitation will increase the ‘capacity’ of your …insert musculoskeletal tissue here….” Defining ‘tissue capacity’: A core concept for clinicians. British Journal of Sports Medicine.
Coombes, B. K., Bisset, L., & Vicenzino, B. (2015). Management of Lateral Elbow Tendinopathy: One Size Does Not Fit All. Journal of Orthopaedic & Sports Physical Therapy.
Coombes, B.K., Connelly, L., Bisset, L., Vicenzino, B. (2016). Economic evaluation favours physiotherapy but not corticosteroid injection as a first-line intervention for chronic lateral epicondylalgia: evidence from a randomised clinical trial. Br J Sports Med.
Cullinane, F.L., Boocock, M.G., Trevelyan, F.C. (2014). Is eccentric exercise an effective treatment for lateral epicondylitis? A systematic review. Clin Rehabil.
Drew, B.T., Smith, T.O., Littlewood, C., Sturrock, B. (2014) Do structural changes (eg, collagen/matrix) explain the response to therapeutic exercises in tendinopathy: a systematic review. Br J Sports Med.
Duchesne, E., Dufresne, S.S., Dumont, N.A. (2017). Impact of Inflammation and Anti-inflammatory Modalities on Skeletal Muscle Healing: From Fundamental Research to the Clinic. Phys Ther.
Fernández-Carnero, J., Fernández-de-Las-Peñas, C., de la Llave-Rincón, A.I., Ge, H.Y., Arendt-Nielsen, L. (2007). Prevalence of and referred pain from myofascial trigger points in the forearm muscles in patients with lateral epicondylalgia. Clin J Pain.
Fernández-Carnero, J., Fernández-de-las-Peñas, C., de la Llave-Rincón, A.I., Ge, H.Y., Arendt-Nielsen L. (2008). Bilateral myofascial trigger points in the forearm muscles in patients with chronic unilateral lateral epicondylalgia: a blinded, controlled study. Clin J Pain.
Joseph, M.F., Taft, K., Moskwa, M., Denegar, C.R. (2012). Deep friction massage to treat tendinopathy: a systematic review of a classic treatment in the face of a new paradigm of understanding. J Sport Rehabil.
López-de-Celis, C., Barra-López, M.E., González-Rueda, V., ... Tricás-Moreno, J.M. (2018). Effectiveness of diacutaneous fibrolysis for the treatment of chronic lateral epicondylalgia: a randomized clinical trial. Clin Rehabil.
Mallows, A., Debenham, J., Walker, T., Littlewood, C. (2017). Association of psychological variables and outcome in tendinopathy: a systematic review. Br J Sports Med.
Mallows, A.J., Debenham, J.R., Malliaras, P., Stace, R., Littlewood, C. (2018). Cognitive and contextual factors to optimise clinical outcomes in tendinopathy. Br J Sports Med.
Page, P. (2010). A new exercise for tennis elbow that works! N Am J Sports Phys Ther. (OPEN ACCESS)
Piper, S., Shearer, H. M., Côté, P., Wong, J. J., Yu, H., Varatharajan, S., . . . Taylor-Vaisey, A. L. (2016). The effectiveness of soft-tissue therapy for the management of musculoskeletal disorders and injuries of the upper and lower extremities: A systematic review by the Ontario Protocol for Traffic Injury management (OPTIMa) collaboration. Manual Therapy.
Rio, E., Kidgell, D., Moseley, G.L., ... Cook, J. (2016). Tendon neuroplastic training: changing the way we think about tendon rehabilitation: a narrative review. Br J Sports Med.
Rio, E., Docking, S.I. (2018). Adaptation of the pathological tendon: you cannot trade in for a new one, but perhaps you don’t need to? Br J Sports. https://www.ncbi.nlm.nih.gov/pubmed/28724715
Segretin, F., Paris, G., Cheriet, S., Delarue, Y. (2016). Rehabilitation and auto-exercises protocol in patients with chronic lateral epicondylitis: 6 months follow-up. Ann Phys Rehabil Med.
Sims, S.E., Miller, K., Elfar, J.C., Hammert, W.C. (2014). Non-surgical treatment of lateral epicondylitis: a systematic review of randomized controlled trials. Hand (N Y).
Shmushkevich, Y., Kalichman, L. (2013). Myofascial pain in lateral epicondylalgia: a review. J Bodyw Mov Ther.
Spang, C., Alfredson, H. (2017). Richly innervated soft tissues covering the superficial aspect of the extensor origin in patients with chronic painful tennis elbow - Implication for treatment? J Musculoskelet Neuronal Interact.
Sutton, D., Gross, D. P., Côté, P., Randhawa, K., Yu, H., Wong, J. J., . . . Taylor-Vaisey, A. (2016). Multimodal care for the management of musculoskeletal disorders of the elbow, forearm, wrist and hand: A systematic review by the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration.
Tyler, T.F., Nicholas, S.J., Schmitt, B.M., Mullaney, M., Hogan, D.E. (2014). Clinical outcomes of the addition of eccentrics for rehabilitation of previously failed treatments of golfers elbow. Int J Sports Phys Ther. (OPEN ACCESS)
Uygur, E., Aktaş, B., Özkut, A., Erinç, S., Yilmazoglu, E.G. (2017). Dry needling in lateral epicondylitis: a prospective controlled study. Int Orthop.
Vicenzino, B. (2015). Tendinopathy: Evidence-Informed Physical Therapy Clinical Reasoning. J Orthop Sports Phys.
Yi, R., Bratchenko, W.W., Tan, V. (2018). Deep Friction Massage Versus Steroid Injection in the Treatment of Lateral Epicondylitis. Hand (N Y).