Elbow pain

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LATERAL EPICONDYLITIS

(TENNIS ELBOW)

 

Client Problem:

Massuer’s Perspective:

Client presented with the following signs and symptons of local pain to right lateral elbow joint and forearm pain, constant ache which is exacerbated by use. Man, aged 40 years of age who works as a builder/shopfitter and engages in rigorous daily activities for 8-10 hours daily over last 24+ years. No direct swelling or bruising to the region.

Assessment shows tenderness just distal to the lateral epicondyle in the area of the extensor carpi radialis brevis (ECRB) muscle. Upon wrist extension, gripping (hand shake test) or supination/radial deviation (not flexion or pronation) against resistance provokes the patients’ symptoms.

Proposed Lateral epicondylytis on right arm caused by work related overuse from tools, also known as “Tennis Elbow” as this occurs at the common extensor tendon that originates from the lateral epicondyle causing acute pain upon extension of the forearm. No referring pain. Onset has developed over the years and become unbearable over the last month to two months. Pain locally to the lateral epicondyle region on right arm has increased gradually, getting worse to reach currently pain level of 8-9 in mornings reducing to only 6-7 during the day and aches most nights. Pain relieved by rest on weekends only. Aggravation first thing in morning especially on extension of right elbow.

Client has seen his General Practitioner last week who has prescribed him with medication – anti inflammatory which has eased pain slightly. Otherwise client’s general health is good and recent surgery to remove sist on back not relevant to this condition.

 

Client Perspective:

Patient presented with “Right elbow soreness – feels stiff and aching, difficult to straighten. Pain on top of elbow joint is worse especially first thing in the mornings. Upper arm isn’t affected with this pain, and upper back and neck have general soreness but main concern is at elbow. No referring pain.”

Works as builder which aggravates pain – handles heavy power tools daily for 8-10 hours, 5-6 days a week. He has been working in this field for 24 years. No X-rays or MRI scans have been requested by General Practioner at this stage.

 

 

 

Relevant pathology:

Lateral epicondylitis pathology refers to the involvement of inflammatory processes of the radial humeral bursa, synovium, periosteum, and the annular ligament. However, Nirschi and Pettrone #1,   attributed the cause to microscopic tearing with formation of reparative tissue in the origin of the extensor carpi radialis brevis (ECRB) muscle. This micro tearing and repair response can lead to macroscopic tearing and structural failure of the origin of the ECRB muscle. #2   Lateral epicondylitis has also been explained as a degenerative condition rather than caused by inflammation.#3

During early experiments, it was thought that tennis elbow was primarily caused by overexertion. Studies have shown that trauma such as direct blows to the epicondyle, a sudden forceful pull, or forceful extension have caused more than half of these injuries.

One explanation of how tennis elbow may come about is proposed by Cyriax. The theory states that there are microscopic and macroscopic tears between the common extensor tendon and the periosteum of the lateral humeral epicondyle. An operation conducted in this study showed that 28 out of 39 patients showed tearing at the tendon cuff. Kaplan stated that the radial nerve was significantly involved in tennis elbow. He noted the constriction of the radial nerve by adhesions to the capsule of the radiohumeral joint and the short extensor muscle of the wrist. Evidence found that many differed in how they contracted tennis elbow. Disorders such as calcification of the rotator cuff, bicipital tendinitis, or carpal tunnel syndrome may increase chances of tennis elbow.

The pathophysiology of lateral epicondylitis is degenerative. Non-inflammatory, chronic degenerative changes of the origin of the extensor carpi radialis brevis (ECRB) muscle are identified in surgical pathology specimens. It is unclear if the pathology is affected by prior injection of corticosteroid.

The extensor digiti minimi also has a small origin site medial to the elbow which can be affected by this condition. The muscle involves the extension of the little finger and some extension of the wrist allowing for adaption to “snap” or flick the wrist – usually associated with a racquet swing. Most often, the extensor muscles become painful due to tendon breakdown from over-extension. Improper form or movement allows for power in a swing to rotate through and around the wrist – creating a moment on that joint instead of the elbow joint or rotator cuff. This moment causes pressure to build impact forces to act on the tendon causing irritation and inflammation. Cont. overpage

 

 

 

#1 – Nirschi RP, Pettrone FA Tennis Elbow – Surgical treatment for lateral epicondylitis

#2 – http://emedicine.medscape.com/article/1231903-overview

#3 – p274 of Clinical Sports Medicine – Second Edition – Peter Brukner and Karim Khan

 

 

Relevant pathology cont:

With the overuse theory, the ECRB has a small origin and does transmit large forces through its tendon during repetitive grasping. It has also been implicated as being vulnerable during shear stress during all movements of the forearm. #4

While it is commonly stated that lateral epicondylitis is caused by repetitive microtrauma/ overuse, this is a speculative etiological theory with limited scientific support that is likely overstated.[#5]

Other speculative risk factors for lateral epicondylitis include taking up tennis later in life, unaccustomed strenuous activity, decreased mental chronometry and speed and repetitive eccentric contraction of muscle (controlled lengthening of a muscle group).#4

Other explanations for lateral elbow pain is overuse syndrome related to excessive wrist extension. Traditionally known as “tennis elbow”. Despite being more common condition in non tennis players, or lateral epicondylitis which has also been deemed inappropriate clarification as the side of the abnormality is usually just below the lateral epicondyle and the primary pathology is often degenerative rather than inflammatory.#6

“The primary pathological process involved in this (lateral elbow pain) condition, is degeneration of the extensor carpi radialis brevis (ECRB) tendon, usually within 1-2cm of its attachment to the common extensor origin at the lateral epicondyle. This condition will be referred to as extensor tendinopathy.   Other conditions thay may cause lateral elbow pain include synovitis of the radiohumeral joint, radiohumeral bursitis, and entrapment of the posterior interosseous branch of the radial nerve (radial tunnel syndrome). These conditions may exist by themselves or in conjunction with extensor tendinopathy.” #6

Pain from this condition can vary from relatively trivial pain to an almost incapacitating pain that may keep the patient awake at night. It is important to note whether the pain is aggravated by minor activities such as opening door handle or picking up a cup, or whether it requires repeated activity like tennis or bricklaying etc, to become painful.

Pain may radiate into the lateral aspect of the forearm. This may be consistent with posterior interosseous nerve entrapment or irritation of other neural structures. If pain is closely related to the activity level, it is more likely to be a mechanical origin. If pain is persistent, unpredictable or related to posture, referred pain should be considered. #6

 

 

#4 – http://en.wikipedia.org/wiki/Tennis_elbow

#5 – Boyer MI, Hastings H (1999).”Lateral tennis elbow” Journal of Shoulder and Elbow Surgery

#6 – Clinical Sport Medicine by Brukner & Khan – Revised 2nd Edition

 

 

Relevant pathology cont:

“In the traditional medical view, tennis elbow (lateral epicondylitis) and golfer’s elbow are forms of tendinitis. The presumption is that the tendons around your elbow have suffered microscopic tears through injury or overuse. Unfortunately, the term “tendinitis” has become a virtual synonym for pain. Even an official medical diagnosis of tendinitis or epicondylitis is often based on no more evidence than your statement that your elbow hurts.

This long-standing conventional medical mindset is disputed by Doctors Janet Travell and David Simons in their widely acclaimed medical textbook, Myofascial Pain and Dysfunction: The Trigger Point Manual.

Extensive research by Travell and Simons has shown that myofascial trigger points (tiny contraction knots) in overworked or traumatized forearm muscles, not tendinitis, are the primary cause of pain in the elbow.” #7 See Figure # 1

 

 

1

The illustration shows a trigger point in the extensor carpi radialis longus muscle. This is the most common cause of pain in the outer elbow, commonly called tennis elbow, elbow tendinitis, or lateral epicondylitis.

Trigger points in other forearm muscles cause numbness, tingling, burning, swelling, weakness, and stiffness in the wrists, hands, and fingers.#7

 

 

Figure 1 – Trigger Point location for treatment of lateral epicondylitis – http://www.triggerpointbook.com/tennisel.htm

Certain movements, usually those involving wrist extension or gripping, will aggravate mechanical pain. Referred pain is affected by prolonged posture, such as lengthy periods seated at a desk or in a car. Associated sensory symptoms, such as pins and needles or numbess, may indicate a neural component.

“Lateral Epicondylis” referring to lateral elbow pain can also be contributed to from the cervical and upper thoracic spines and neural structures in this region. Therefore examination of the spine is essential when treating anyone with lateral elbow pain.

 

 

 

#7 – http://www.triggerpointbook.com/tennisel.htm

Anatomical Terms

Anatomical Structures in Region:

Based on “Tennis elbow” or “Lateral epicondylitis” as an inflammation of the tendons that join the forearm muscles on the outside of the elbow, this causes the forearm muscles and tendons become damaged from overuse – repeating the same motions again and again. This leads to pain and tenderness on the outside of the elbow.

The elbow joint is made up of three bones – your upper arm bone (humerus) and the two bones in your forearm (radius and ulna). There are bony landmarks at the distal end of the humerus called epicondyles. The bony landmark on the lateral side of the elbow is called the lateral epicondyle. Ligaments within this region include the articular capsule (encasing joint), radial collateral ligament and the radial annular ligament. Together with tendons (specifically common extensor tendon insertion) and muscle attachments, these all hold the elbow joint together – Ref to Figure 2 for bones and ligaments below.

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Figure 2 –Bones and Ligaments of Elbow Joint – Tortora & Grabowski – Principles of Anantomy & Physiology

 

#8 – http://orthoinfo.aaos.org/topic.cfm?topic=a00068

 

Anatomical Structures in Region: cont.

Muscles and tendons involved is this region includes those seen in the following images from Figures 2 to 9. Your forearm muscles extend your wrist and fingers. Your forearm tendons — often called extensors — attach the muscles to bone. They attach on the lateral epicondyle. The tendon usually involved in tennis elbow is called the Extensor Carpi Radialis Brevis (ECRB). #8   See Fig 3. See Fig 4 for location of pain in lateral epicondylitis

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Figure 3 – Extensor Tendon Insertion @ Lateral Epicondyle from The Body Almanac. © American Academy of Orthopaedic Surgeons, 2003.

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Figure 4 – Extensor Tendon Insertion location when arm extended and gripping – Griffin L – Essentials of Musculoskeletal Care, Third Edition © American Academy of Orthopaedic Surgeons, 2005

#8 – http://orthoinfo.aaos.org/topic.cfm?topic=a00068

 

 

Extensor Muscles involved in lateral view. – See Figure 5

Figure 5 – Extensor Muscles @ Lateral Epicondyle – Trial Guide to the Body – Andrew Biel, Fully Revised 4th Edition

5

Extensor Tendons at the Lateral Epicondyle – See Figure 6

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Figure 6 – Extensor Tendon @ Lateral Epicondyle – Trial Guide to the Body – Andrew Biel, Fully Revised 4th Edition

Extensor Carpi Radialis longus and Brevis– See Figure 7

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Figure 7 – Extensor Carpi Radialis Longus and Brevis – Hand Shake Test – Trial Guide to the Body – Andrew Biel, Fully Revised 4th Edition

Anatomical Relationships

Top of page

 

Recent studies show that tennis elbow is often due to damage to a specific forearm muscle. The extensor carpi radialis brevis (ECRB) muscle helps stabilize the wrist when the elbow is straight. When the ECRB is weakened from overuse, microscopic tears form in the tendon where it attaches to the lateral epicondyle. This leads to inflammation and pain.#8 and See Figure 8

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Figure 8 – Microscoptic tears in extensor tendon – http://www.mdguidelines.com/epicondylitis-medial-and-lateral

The ECRB may also be at increased risk for damage because of its position. As the elbow bends and straightens, the muscle rubs against bony bumps. This can cause gradual wear and tear of the muscle over time.

Athletes are not the only people who get tennis elbow. Many people with tennis elbow participate in work or recreational activities that require repetitive and vigorous use of the forearm muscle.

Painters, plumbers, and carpenters are particularly prone to developing tennis elbow. Studies have shown that auto workers, cooks, and even butchers get tennis elbow more often than the rest of the population. It is thought that the repetition and weight lifting required in these occupations leads to injury.

Most people who get tennis elbow are between the ages of 30 and 50, although anyone can get tennis elbow, lateral epicondylitis, if they have the risk factors. In racquet sports like tennis, improper stroke technique and improper equipment may be risk factors.

Lateral epicondylitis can occur without any recognized repetitive injury. This occurrence is called “insidious” or of an unknown cause. #8

#8 – http://orthoinfo.aaos.org/topic.cfm?topic=a00068

 

 

Anatomical Relationships cont.

Other relevant relationships include individuals commonly reporting elbow pain with forceful gripping, and decreased ability to use the wrist most often in the dominant arm. Swelling may occasionally occur. The symptoms may appear suddenly, but more often the onset is gradual and progressive. Over time, the pain may become severe and persist at rest. Pain is localized to the medial or lateral elbow region initially but may progress to involve the muscle mass of the forearm. #9 & See muscles in Figure 9

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Figure 9 – Forearm muscles – ECRBrevis – CUT – Tortora & Grabowski – Principles of Anatomy & Physiology

Individuals may relate a change in activity or increase in size and weight of tools used for a period immediately preceding the onset of pain. Many cases, however, occur without an obvious cause. Client history should inquire about neck and shoulder and elbow injuries to rule out other causes of symptoms. #8

 

#8 – http://orthoinfo.aaos.org/topic.cfm?topic=a00068

#9 – http://www.mdguidelines.com/epicondylitis-medial-and-lateral

Normal function of this region

 

Normal functions available at the elbow joint (hinge joint) include flexion (Normally 140 Degrees) and extension (0 Degrees). At the proximal Radioulna joint (pivot joint) supination (elbow flexed at 90 Degrees – normal range of motion- supination of 0 Degrees with thumb pointing vertical of 85 Degrees), and pronation (elbow flexed at 90 Degrees – normal range of pronation is 160 Degrees with thumb pointing vertical 75 Degrees). Without pain.

 

Function ability at the wrist involves flexion-80 Degrees and extension-70 Degrees, radial deviation and medial deviation and some circumduction.

 

Pain felt with movements of extension and supination at elbow and extension at wrist, indicate the possibility of lateral epicondylitis or tennis elbow. The clients shows

 

Muscles involved with these movements are: Elbow extension – Triceps brachii, Anconeous (strong muscles), Extensor Muscles which all originate at the Common Extensor Tendon such as Extensor Carpi Radialis Longus, Extensor Carpi Radialis Brevis, Extensor Carpi Ulnaris, Extensor Digitorum and Extensor digiti minimi. Elbow supination involves Brachioradialis, supinator and Biceps brachii. Wrist extension utilizes all the Extensor muscles which also allows radial deviation. The most common muscle involved with these actions is Extensor Carpi Radialis Brevis.

 

Other structures within the region include the Brachail, Radial and Ulnar arteries and veins, See Figure 10, together with the radial, median and ulnar nerves –See Figure 11. Lymphatic ducts and nodes are also evident in the region.- See Figure 12

 

The extensor carpi radialis brevis (ECRB) muscle arises from the lateral epicondyle. The ECRB muscle lies deep to the extensor carpi radialis longus (ECRL) muscle and superficial to the joint capsule-See Figure 3. The articular capsule, annular and collateral ligaments are located beneath and just distal to the origin of the ECRB muscle.#2 See Figure 2

 

Upon assessment of the client, he has presented with the above complications in range of motion and pain references as stated above. He also has local tenderness over trigger point areas of the extensor muscles. No swelling is evident which confirms his particular condition is more suitably recognized to be related to myofascial trigger points.

 

#2 – http://emedicine.medscape.com/article/1231903-overview#a04

 

10

Figure 10 – Arteries in region – www.flashcardmachine.com

11

Figure 11 – Nerves of Upper Limb – www.antranik.org

 

 

12

 

Figure 12 – Lymphatics of Region – http://www.celluliteinvestigation.com/wp-content/forum-image-uploads/cellul10/lymph-nodes-arm.jpg

 

 

 

Massage Treatment Regime

 

 

Movement limitations caused by condition & aggravating factors

 

Client suffering from tennis elbow or lateral epicondylitis will suffer from pain on the outer part of elbow, local tenderness over the lateral epicondyle – a prominent part of the bone on the outside of the elbow, Gripping and movements of the wrist hurt, especially wrist extension and lifting movements. Limitations also effect activities that use the muscles that extend the wrist (e.g. pouring a jug,- lifting with the palm down, using screwdriver and heavy tools, are characteristically painful. Also limitations are evident with morning stiffness, limiting range of motion in extension.

The symptoms associated with lateral epicondylitis or tennis elbow are, but are not limited to: radiating pain from the outside of your elbow to your forearm and wrist, pain during extension of wrist, weakness of the forearm, a painful grip while shaking hands or turning a doorknob, and not being able to hold relatively heavy items in the hand. The pain is similar to the pain of the condition known as Golfer’s elbow but the latter occurs at the medial side of the elbow. #4

This condition is aggravated by repetitive and over use in many cases or improper techniques used for example in playing tennis.

 

A painful elbow can also appear to be weak, but exercising for the purpose of strengthening it is not only ineffective, but unnecessary.

 

Myofascial trigger points temporarily weaken muscles that are associated with the elbow as a means of protection from further overuse or abuse. There is no atrophy. Full strength ordinarily returns with normal activity within a short time after trigger points are deactivated.

 

Assessment of Problem – Relevance to Massage

 

The clients pain levels and restriction of movement specifically extension of elbow, is his main concern seeking advice, relief and rehabilitation. He has expressed his dissatisfaction to his GP prescribed pain killers and anti-inflammatories. These methods of treatment give only temporary relief and do not resolve the problem, especially when client isn’t able to rest. Rest is always recommended for tennis elbow, but it’s not the best therapy when trigger points are the cause of the pain.

 

 

 

#4 – http://en.wikipedia.org/wiki/Tennis_elbow

 

 

Assessment of Problem – Relevance to Massage cont..

 

Rest may lull trigger points into a quiet, latent state, but it doesn’t get rid of them. When you resume whatever activity caused the tennis elbow in the first place, the pain comes right back, rarely diminished in the least.

 

Elbow splints or braces inactivate the elbow and give relief while they’re in place, but they only serve as a short-term solution. Immobility can actually make trigger points worse and ultimately increase your pain.#7

 

“Muscle attachments at the elbow can be irritated by the unrelieved tension that trigger points produce in muscles. This can be the direct cause of any inflammation and degenerative changes that develop in the elbow.

 

Even when inflammation is proven to exist, trigger point therapy is the most appropriate treatment, because it goes to the source of the trouble”.#7

 

With the above in mind, trigger point therapy together with oriental cupping would be the methods of choice when treating this condition, with close reassessment and monitoring whether trigger points and deactivating. Also transverse friction is an option to be considered, applied over the Extensor Carpi Radialis Brevis muscle below the lateral epicondyle and just distally where the known trigger point is located. Refer to Figure 1 on page 6.

 

Therapeutic massage techniques and myofascial release of the facial tissue surrounding each muscle would also benefit providing there is no evidence of inflammation. Lymphatic Drainage may also be an option to consider.

 

Treatment would also take into consideration muscles in the shoulder, upper arm and forearm, cervical and thoracic alignment as they all may be involved in sending pain to the outer elbow.

 

Rest is recommended and the application of ice would also be recommended. Limited use of the elbow and wrist preferred with caution advised with exercising area or even over stretching.   Conventional stretching tends to irritate trigger points and can very quickly make your pain worse. Stretching can be useful, but only after the trigger points are gone. Specific stretches are prescribed and client given a take home sheet to refer to, to ensure carried out correctly. See Client Self Help Strategies.- Pages 17-18.

 

 

#7 – http://www.triggerpointbook.com/tennisel.htm

 

Short Term Goals

 

Assessment of Range of Motion and pain levels – Begin with weekly treatments of trigger point therapy, myofascial release and oriental cupping for up to 4-6 months, re-assessing range and pain levels along the way. Deactivation of trigger points and eliminating other areas as a possibility of additional causes for symptoms eg cervical/thoracic spine, upper arm / shoulder etc.

Client to adhere to stretching and exercise regime as seen in self help information on pages 17-18 and advised to limit use to minimum and avoid any overuse, to ensure best possible outcome.

Utilise a forearm brace as this may help relieve symptoms especially if use is necessary whilst undergoing rehabilitation/treatment. Caution advised here to ensure that a false security of improved symptoms not be an indication for continued use/overuse etc.

Medications provided by General Practitioner to be used as required with caution advised here also to ensure true assessments are able to be carried out without interference of pain killers and anti inflammatory’s.

 

Long Term Goals

If after 6 months, the client has adhered to the above and clients range of motion and pain levels did not change or lesson from these treatments, then referral to GP for further examination by way of XRAY, MRI or EMG may be required, or Cortisone Injection, or preferably, referral to a practitioner who is qualified to undertake Myofascial Dry Needling or Acupuncture, to exhaust all attempts to avoid surgery and only consider as a last resort.

 

For further information regarding these options please see “Other Techniques and Referrals to other practitioners” on page 19 and “Recommended Movement Practices” on page 20.

 

Client Self Help Strategies – Take home exercises for client

Self help massage the client can do themselves, is seen in Figure 13 showing massage of the outer forearm with a tennis ball or lacrosse ball against a wall.

Advise client to lean your body against your arm to apply pressure.

Begin 3 or 4 inches below the elbow and roll the ball repeatedly all the way up to the elbow. Six to twelve strokes make a treatment, but treat several times a day.

13

Figure 13 – Self help exercise – http://www.triggerpointbook.com/tennisel.htm


 

Client Take Home – Rehabilitation For Tennis Elbow: The Super 7

The “super 7” exercises are an important part of treatment for tennis elbow. They are designed to strengthen the muscles in the forearm and increase flexibility through stretching. In most cases these exercises will help relieve elbow pain in about 4 to 6 week Each stretching exercise is held for 15 seconds & repeated 2 or 3 times. This pattern is repeated 5 times a day.

 

Exercise 1. Stretching the muscles that extend the wrist (extensor muscles): Straighten the arm out fully and push the palm of the hand down so you feel a stretch across the top of the forearm.

14d

Exercise 2. Stretching the muscles that flex the wrist (flexor muscles): straighten the arm out fully (palm side up), and push the palm downward to stretch. Strengthening exercises are performed twice a day following the stretching exercises. To perform these exercises, the patient sits in a chair with the elbow supported on the edge of a table or on the arm of the chair the wrist hanging over the edge. Use a light weight such as a hammer or soup can when performing the strengthening exercises. Repeat exercises 30 to 50 times, twice a day, but do not push yourself beyond the point of pain.

14d

Exercise 3. Strengthening wrist extensor muscles: Hold the weight in the hand with the palm facing down. Extend the wrist upward so that it is pulled back. Hold this position for 2 seconds and then lower slowly.

14b.gif
Exercise 4. Strengthening wrist flexor muscles: Hold the weight in the hand with the palm up. Pull the wrist up, hold for 2 seconds and lower slowly.

14e

Exercise 5. Strengthening the muscles that move the wrist from side to side (deviator muscles): Hold the weight in the hand with the thumb pointing up. Move the wrist up and down, much like hammering a nail. All motion should occur at the wrist.

14c

Exercise 6. Strengthening the muscles that twist the wrist (pronator and supinator muscles): Hold the weight in the hand with the thumb pointing up. Turn the wrist inward as far as possible and then outward as far as possible. Hold for 2 seconds and repeat as much as pain allows, up to 50 repetitions.

14f

Exercise 7. Massage is performed over the area of soreness. Apply firm pressure using 2 fingers on the area of pain and rub for 5 minutes.

 

14g

If exercise aggravates any of your symptoms, contact a physician or physical therapist These exercises can be used to prevent or rehabilitate injuries in people who play sports or in those who do repetitive forearm work.

Tim L. Uhl, P.T., A.T.,C.

 

Figure 14 – Client Self Help Exercises – The Super 7 – http://www.hughston.com/hha/a.seven.htm

Alternative Treatments

Other Techniques and Referrals to other practitioners

If client didn’t respond to above treatments then Myofascial Dry Needling would be an alternative additional treatment recommended for consideration. This method uses Dry Needling techniques into Myofascial Trigger Points. MTrPs, which defined by Travell and Simons in 1992 as being “hyper-irritable spot, usually within a taut ban of skeletal muscle or in the muscle’s facia The spot is painful on compression and can give rise to characteristic referred pain, tenderness and autonomic behavior”#10.

Myofascial Dry needling into these known locations by a qualified practitioner have also proven to have positive results in reducing pain and increasing range of motion in treating lateral epicondylitis (tennis elbow). Therefore appropriate referral required.

If further diagnoses required, then x-rays may be advisable to rule out arthritis of the elbow.

Magnetic Resonance Imaging (MRI) may be warranted if there are indications of a neck problem or spinal arthritis or herniated disc injury.

Electromyography(EMG) too may be necessary if signs of nerve impingement or compression are evident.

The client’s GP would be required to authorize these additional tests should massage treatments not be successful.

Approximately 90-95% of patients with lateral epicondylitis respond to conservative measures and do not require surgical intervention. Patients whose condition is unresponsive to 6 months of conservative therapy (including corticosteroid injections, are candidates for surgery). #11

 

Should Surgery be required, the client’s General Practioner would be referred to.

 

 

#10 – http://www.filecrop.com/travell-and-simons.html

#11 – http://emedicine.medscape.com/article/1231903-overview#a04

 

 

 

 

Recommended movement practices

On the basis that the above is not relevant to the clients’ condition and approximately 80-95% of patients do have success with non surgical treatment (this would be a last resort option after 6 months of treatment, pending severity of the condition and pain levels) the recommended movement practices would be assessment and management of degrees of range of motion, rest, attend regular treatments, manage inflammation with ice and correct stretching/exercise routines, limit use as much as possible and seek the above recommendations/referrals to other practitioners to ensure the best possible outcome for the client.

If the above failed to improve the client’s condition, then consideration of cortisosteriod injection to assist in relieving symptoms whilst continuing treatment to avoid surgery.

If symptoms did not respond to treatment after 6-12months of correct treatment, surgical procedures involving removal diseased muscle and reattaching healthy muscle back to the bone may be necessary. Open surgery is the most common approach involving an incision over the elbow, or arthroscopic surgery using tiny instruments and small incisions.#8

As with any surgery, risk factor involved in elbow surgery should be considered, such as infection, possibility of damage to nerve and or blood vessels, possible prolonged rehabilitation, loss of strength, loss of flexibility and the need for further surgery.

Rehabilitation after surgery involves immobilizing with a splint for a week, then stitches removed. Exercises to stretch the elbow and restore flexibility are required before gradual strengthening exercises are started about 2 months after surgery. Usually recovery from this surgery is up to 4-6 months before returning to regular activity. Majority of elbow surgery is considered successful (80 to 90%), however loss of strength is not uncommon. #8

 

 

 

 

 

 

 

#8 – http://orthoinfo.aaos.org/topic.cfm?topic=a00068

 

 

Summary

The most common type of elbow pain is what is often referred to as ‘tennis elbow’. Interestingly most people who suffer from this condition do not play tennis! It is characterised by pain on the outer side of the elbow, aggravated by gripping or lifting type activities, especially involving degeneration over a longer period of time.

This condition is caused by weakness and inflammation of the ‘extensor tendons’ as they attach into the lateral epicondyle bone of the elbow. It has also been described as micro tears within the tendon or muscle insertion, or activated trigger points within the muscle belly, requiring deactivation.

Treatment involves anti-inflammatory techniques such as ice application, along with soft tissue massage therapy, trigger point therapy, myofascial therapy, oriental cupping techniques, lymphatic drainage and eventually stretching and strengthening exercises to condition the tendon to better cope with activities and reduce pain and inflammation.

These treatments should be carried out for a period of approximately 6 months before surgery is considered.

General Practitioner medications for pain and inflammation or even cortisone/steroid injections can relieve some of the symptoms of Lateral Epicondylitis whilst undergoing treatment yet caution is warranted to ensure true assessments can be made and monitored. Whilst medicated the elbow may appear to have improved by covering up the real levels of pain and range of motion. Also the possibility of incorrect or overuse is a concern here too.

 

 

List of References

 

#1 – Nirschi RP, Pettrone FA Tennis Elbow – Surgical treatment for lateral epicondylitis

#2 – http://emedicine.medscape.com/article/1231903-overview

#3 – p274 of Clinical Sports Medicine – Second Edition – Peter Brukner and Karim Khan

#4 – http://en.wikipedia.org/wiki/Tennis_elbow

#5 – Boyer MI, Hastings H (1999).”Lateral tennis elbow” Journal of Shoulder and Elbow Surgery

#6 – Clinical Sport Medicine by Brukner & Khan – Revised 2nd Edition

#7 – http://www.triggerpointbook.com/tennisel.htm

#8 – http://orthoinfo.aaos.org/topic.cfm?topic=a00068

#9 – http://www.mdguidelines.com/epicondylitis-medial-and-lateral

#10 – http://www.filecrop.com/travell-and-simons.html

#11 – http://emedicine.medscape.com/article/1231903-overview#a04

 


 

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