Massage Therapy for People with Elbow Pain

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Massage Therapy for People with Elbow Pain

For people with tendon pain a multidisciplinary approach including exercise therapy and load-management are first line treatments. In addition, manual therapy may be a useful adjunct to help manage pain and other associated symptoms.

Pathophysiology of Elbow Pain

Lateral elbow tendinopathy (LET), also known as Tennis elbow is described as pain at the outside of the elbow and in the upper forearm where the muscle tendon attaches to the bone. Medial elbow tendinopathy (MET), also known as Golfer's elbow is described as pain at the inside of the elbow and in the upper forearm where the muscle tendon attaches to the bone. It is important to keep in mind that the presentation of pain in a tendon does not always mean that the tendon itself is the primary contributor to pain. Other conditions involving the elbow could co-exists with common forms of elbow pain including arthritis, sports injuries, and nerve entrapments.

A Whole Person Approach for Massage Therapists

Within an evidence-based framework for massage therapy there are six components that make up a treatment plan (informed consent and shared decision making, assessment, outcome measurements, education and reassurance, multimodal treatment, reevaluation and reassessment).

Informed Consent and Shared Decision Making

Informed consent will include a discussion about natural history and the effects of no treatment, as well as the possible risks and benefits of receiving treatment. The therapist and patient will then work together to develop a plan of care based on the individualized goals and needs of the patient. This approach gives people the opportunity to be engaged in their own health through the process of shared decision making.

Assessment

A comprehensive assessment assists the clinician come up with a treatment plan that is best suited to each individual. It may involve a physical assessment and detailed health history intake to gather information about patients' limitations, course of pain and can help identify those with a higher likelihood of red flags (serious underlying pathologies) or yellow flags (prognosis factors for delayed recovery). This may also help establish therapeutic alliance and identify the biological, psychological, social and contextual factors contributing to pain and disability.

  • Red Flags (serious underlying pathologies) - Red flags are signs and symptoms that raise suspicion of serious underlying pathology, if a serious pathology is suspected a clinical decision should be made to refer the patient to an appropriate healthcare practitioner. For the general population there are several red flags to be mindful of such as, substantial motor/sensory loss or progressive neurological deficits, fractures or osteoporosis risk/fragility fracture, acute infection (fever/chills/malaise), joint dislocation, peripheral arterial disease and venous thromboembolism.

  • Yellow Flags (risk factors for delayed recovery) - This assessment process could also include screening questionnaires, such as the Orebro musculoskeletal pain questionnaire or Optimal Screening for Prediction of Referral and Outcome Yellow Flag (OSPRO-YF) to help identify yellow flags or identify patients at risk of poor prognosis. If the patient develops worsening physical or psychological symptoms consider a referral to counseling or an appropriate healthcare professional for further evaluation.

  • Physical Assessment - A physical assessment could include palpation, observing gait, neurological screening tests, assessing mobility and/or muscle strength. Interpret assessment results in the context of all assessment findings and implement an individualized treatment plan that is based on the assessment findings and goals of the patient.

  • Orthopedic Tests - Clinicians could also incorporate one or more of the following physical assessment tools and interpret assessment results in the context of all other assessment findings.

    • Elbow Valgus and Varus Stress Tests

    • Moving Valgus Stress Test of the Elbow

    • Cozen’s Test

    • Mill’s Test

    • Medial Epicondylitis Test (Golfers Elbow)

    • Tinel’s Sign at the Elbow (Cubital Tunnel Syndrome)

    • Pronator Teres Syndrome Test

    • Upper Limb Tension Tests (1, 2, 3, & 4)

Outcome Measurements

Clinicians should use appropriate tools and strategies to monitor and evaluate the effectiveness of the treatment plan and adapt care accordingly. This could include incorporating one or more of the following outcome measurements when assessing and monitoring patient progress:

  • Self-Rated Recovery Question

  • Patient-specific Functional Scale

  • Brief Pain Inventory (BPI)

  • Visual Analog Scale (VAS)

  • Patient-Rated Elbow Evaluation (PREE)

  • Patient-Rated Tennis Elbow Evaluation (PRTEE)

  • DASH Outcome Measure

  • Upper Extremity Functional Index

Education & Reassurance

Focus on the concept of a person-centered approach that addresses biological, psychological, and social and contextual factors and empowers people with shared decision making. Provide reassurance and facilitate an evidence based understanding of treatment options and encourage the use of active approaches to help manage symptoms. Reassess the persons status at each visit for new or worsening symptoms, or satisfactory recovery.

Multimodal Treatment

A multimodal treatment approach can have an effect on the musculoskeletal system (mediated by a whole-body neuro-endocrine-immune response) which may improve the body’s ability to recover from repetitive strain injuries.

  • Manual Therapy - A massage therapy treatment plan for elbow pain should be implemented based on patient-specific assessment findings and patient tolerance. Manual therapy (skin rolling, soft tissue massage,nerve-directed stretching, and joint mobilization) may help disperse intraneural edema and flush inflammatory cells (cytokines and chemokines). Structures to keep in mind while assessing and treating patients suffering from elbow pain may include neurovascular structures and investing fascia of:

    • Scalene Muscle Group (anterior scalene, middle scalene, and posterior scalene)

    • Pectoral Region (pectoralis major, pectoralis minor, serratus anterior and subclavius)

    • Rotator Cuff (subscapularis, infraspinatus, teres minor, supraspinatus)

    • The Upper Arm (biceps brachii, brachialis, coracobrachialis, triceps brachii)

    • 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)

    • Carpal Bones (trapezium, trapezoid, capitate, hamate, scaphoid, lunate, triquetrum, pisiform)

  • Self-Management Strategies - Massage therapists not only provide hands-on treatment they can also develop self-management programs to help patients manage symptoms. Simple home-care recommendations such as stretching and strengthening exercises (using hand-held weights and therapeutic bands) for the forearm may be useful for people with elbow pain (Karanasios et al., 2021). Rehabilitation could include progressive exercises (Forearm stretches held for 30 seconds and repeated three times before and after loading exercises. Isometric exercises held for up to 60 seconds and repeated five times, once daily. Concentric and eccentric loading could be performed in three sets of 10–15 repetitions, once daily.). It may also be beneficial for the patient to use a counterforce elbow brace.

LIFESTYLE FACTORS AND TREATMENTS THAT ENHANCE PLASTICITY IN A FAVORABLE ENVIRONMENT CAN HAVE A SIGNIFICANT EFFECT ON PHYSICAL AND MENTAL HEALTH. THESE OUTCOMES MAY BE ATTRIBUTED TO SPECIFIC EFFECTS (PHYSIOLOGICAL, NEUROBIOLOGICAL), CONTEXTUAL EFFECTS (PATIENT-THERAPIST RELATIONSHIP, SET AND SETTING), AND NON-SPECIFIC EFFECTS (NATURAL HISTORY, REGRESSION TOWARD THE MEAN).

Reassessment and Reevaluation

Prognosis is good for the conservative management of elbow pain (Lucado et al., 2022; Piper et al., 2016). About 90% of people with untreated tennis elbow achieve symptom resolution at 1 year (Ikonen et al., 2022). Clinicians should work in partnership with patients to develop a person-centered care plan that considers best available evidence and the patient's goals, values, and preferences. If appropriate, start with multi-modal conservative care (education and reassurance, exercise, manual therapy, hydrotherapy, acupuncture, etc.) and reassess the patient’s status at each visit for new or worsening symptoms, or satisfactory recovery. Then the patient is discharged, treatment is continued, or treatment is escalated based on response to the initial treatment plan, risk/benefit assessment and shared decision making.

Key Takeaways

Massage therapy is a clinically-oriented healthcare option that can improve quality of life for patients with a variety of conditions. In terms of clinical responses (mediated by the neural-endocrine-immune system) outcomes may be attributed to specific effects (affective touch, mechanical factors, and neurological factors), contextual effects (patient-therapist relationship, set and setting), and non-specific effects (natural history, regression toward the mean). Massage therapy can be used as part of a multidisciplinary approach that supports lifestyle factors (sleep, stress, and physical activity). An integrated multidisciplinary approach can have a profound effect on chronic disease progression. Depending on the person’s needs and goals massage therapists are able to incorporate a number of rehabilitation strategies based on patient-specific assessment findings including, but not limited to:

  • Comprehensive assessment and screening for underlying pathologies (red flags & yellow flags)

  • Education and reassurance (person-centered communication, shared decision making, and active coping strategies)

  • Manual therapy (soft tissue massage, neural mobilization, joint mobilization)

  • Self-management strategies (mindfulness-based interventions, hydrotherapy, sleep hygiene, and remedial exercise programs incorporating stretching, strengthening, and physical activity)

References and Sources

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Ikonen, J., Lähdeoja, T., Ardern, C. L., Buchbinder, R., Reito, A., & Karjalainen, T. (2022). Persistent Tennis Elbow Symptoms Have Little Prognostic Value: A Systematic Review and Meta-analysis. Clinical orthopaedics and related research, 480(4), 647–660. https://doi.org/10.1097/CORR.0000000000002058

Jefferson-Falardeau, J., & Houle, S. (2019). Chiropractic Management of a Patient With Radial Nerve Entrapment Symptoms: A Case Study. Journal of chiropractic medicine, 18(4), 327–334. https://doi.org/10.1016/j.jcm.2019.07.003

Karanasios, S., Korakakis, V., Whiteley, R., Vasilogeorgis, I., Woodbridge, S., & Gioftsos, G. (2021). Exercise interventions in lateral elbow tendinopathy have better outcomes than passive interventions, but the effects are small: a systematic review and meta-analysis of 2123 subjects in 30 trials. British journal of sports medicine, 55(9), 477–485. https://doi.org/10.1136/bjsports-2020-102525

Karjalainen, T., & Buchbinder, R. (2023). Is it time to reconsider the indications for surgery in patients with tennis elbow?. The bone & joint journal, 105-B(2), 109–111. https://doi.org/10.1302/0301-620X.105B2.BJJ-2022-0883.R1

Lucado, A. M., Day, J. M., Vincent, J. I., MacDermid, J. C., Fedorczyk, J., Grewal, R., & Martin, R. L. (2022). Lateral Elbow Pain and Muscle Function Impairments. The Journal of orthopaedic and sports physical therapy, 52(12), CPG1–CPG111. https://doi.org/10.2519/jospt.2022.0302

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