Tennis elbow, or lateral epicondylitis, is a common condition causing pain in the elbow due to overworked or injured forearm muscles and tendons. While often associated with tennis players, it can affect anyone engaging in repetitive arm movements. This article explores the effectiveness of massage therapy, particularly deep friction massage, in treating tennis elbow, alongside other treatment options and preventative measures.
Understanding Tennis Elbow
Tennis elbow specifically causes pain that starts on the outside bump of the elbow, the lateral epicondyle. The forearm muscles that bend the wrist back (the extensors) attach on the lateral epicondyle and are connected by a single tendon. Tendons connect muscles to bone. Tennis players most commonly suffer from this type of injury due to the repetitive forceful movements of the wrist and elbow while gripping a racquet, but anyone who engages in activities that require repeated movements of the arms, elbows, or wrists may experience tennis elbow. Tennis elbow typically affects a person’s dominant arm, but may develop in either arm.
Causes and Types of Tennis Elbow
Tennis elbow occurs when these muscles and tendons are overused without being built up. If you don’t regularly strengthen your forearms, these repetitive motions will fatigue and injure the muscle.
There are two main ways tennis elbow can develop:
- Muscular Tennis Elbow: This is related to muscle fatigue from low-impact repetitive motions. Using the arm as normal will make it feel sore and stiff. People with low impact tennis elbow often have trouble typing, writing, or even pouring a cup of coffee.
- Tendonitis Tennis Elbow: Activities where the arm is absorbing a lot of impact, such as competitive sports, can lead to very small tears in the tendon. This pain is overwhelmingly apparent. Tendonitis will cause pain whenever the tendon is flexed and held in place. Flexing and holding the wrist will be very painful when tendonitis is present.
The Role of Massage Therapy in Treating Tennis Elbow
Massage therapy, especially advanced techniques, is increasingly recognized as a valuable component in treating tennis elbow. The key is to address the underlying causes of the injury, which often involve muscle adhesions and restricted blood flow.
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The "Missing Link"
Massage therapy is the “Missing Link” when it comes to treating the true, underlying causes of Tennis Elbow. And reversing that nasty, vicious injury cycle that few things touch. Because nothing else “get's into” the muscle and tendon restrictions at the root of it better. Nothing gets into and releases the “issues in the tissues,” like good, old-fashioned, hands-on Massage Therapy.
Addressing Misconceptions About Inflammation
Many less-experienced Massage Therapists may avoid your Tennis Elbow injury and tell you not to “disturb” it yourself because of Inflammation. But nothing could be further from the truth. Most cases of Tennis Elbow are in desperate need of literally being “disturbed!” Liberated from their constricting, claustrophobic braces and mobilized, released - stretched and strengthened.
You would not actually do deep massage on an area that was truly inflamed, significantly swollen and/or recently injured (Acutely injured, like a sprain, strain or a fracture). However, that is almost never the issue with Tennis or Golfer's Elbow. It's NOT a sprain or a strain - (types of tears)…It's NOT inflamed - (not significantly, anyway)…It's not swollen - (I've never seen a swollen Tennis Elbow)…It's not even Tendonitis (usually.) It's almost always something called Tendinosis, which is not an inflammatory condition by nature.
Mobilization and Circulation
What most people have, though - What I call a “classic case” of Tennis Elbow, is a tendon or tendons that have become overloaded and have begun to break down. (Tendinosis) And that breakdown - the injury - is usually more gradual and microscopic. Think “Micro-Trauma” and picture a rope that has gotten frayed and its fibers have gotten a little rotten in places… Rather than a “big rip” or tear (which is what people too often imagine, and is actually rare.)
What has happened to those tendons is a degenerative breakdown process that's in desperate need of healing. But that healing isn't happening - The tendon's regeneration process has been overwhelmed and has failed (for reasons medical researchers still don't really seem to understand) It's stuck - both literally and figuratively. The healing process is stuck, in the sense that the healing and repair of the tendon has stalled and failed to keep up with the damage, And the muscles and tendons are usually Literally stuck! - (“Gummed up” with what we call 'Ahesions') In the simplest terms, stuckness and stagnation are the essence of Tennis Elbow.
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So, what does it take to reverse this nasty, stuck state of affairs? Mobilization and circulation! With Massage Therapy as the key tool to unlock the stuckness. My recipe, my formula for breaking this vicious cycle is to physically get in there (with advanced Massage techniques) and release the stuckness and to bring much-needed blood flow to the tendons (to break the state of stagnation.)
Advanced Massage Techniques
There are usually tons of of sticky Ahesions binding layers of muscles in the forearm together. And this a very sneaky, insidious process that happens over months and even years, gradually causing your muscles to become more and more restricted… often without producing much in the way of symptoms that would bring your attention to it!
The consequences are twofold: The tighter and more restricted / stuck the muscles get, the weaker they get… AND the more they tend to pull or “drag” on and tax their tendons From my perspective (and it seems pretty intuitive) this is the direct cause of the excessive load that eventually damages the tendon(s). What are people told, though? Blame “Dr. Evil” - Inflammation! - Ice it! Brace it… Rest it… Inject it! NO! Pleeeease don't do any of those things!
Just like funky, nasty, stagnant water needs oxygen and movement to clear, damaged, degenerated tendons need circulation - Blood flow - MOTION to heal!… Not ice, cold and constriction - Or complete and “total rest” ( Read more about why rest is not the answer here ) We need to gently continue moving and to mobilize the area with Massage Therapy to bring better circulation and to literally break up the stuckness; the sticky ahesions in the muscles. And we need to stimulate those tendons - Not leave them alone.
There are TWO major goals, and one minor, when it comes to treating the muscular and tendon issues in the tissues.
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- Releasing muscle adhesions,
- Stimulating the tendons,
- And, sometimes, separating the tendons
And there are only two Advanced Massage Therapy techniques you really need for treating your own Tennis Elbow (and possibly an optional third)…
- Pin And Stretch - A Muscle Adhesion-Releasing Technique: To restore normal muscular flexibility (to take the load off the tendons)
- Cross Fiber Friction - A Tendon-Stimulating Technique: To encourage circulation, and to physically disturb and break the cycle of stagnation that happens in the tendons.
- Press And Twist - A Tendon-Separating Technique: To separate the tendons at - and just above the Epicondyle (the "Tennis Elbow spot")
These techniques are believed to be effective because they address the root causes of tennis elbow, promoting healing and restoring proper function.
Deep Friction Massage: A Closer Look
Deep friction massage is a specific technique that involves applying firm pressure with the fingertips in deep circular motions over the area of maximal tenderness. This technique aims to:
- Stimulate Local Inflammation: Deep friction massage stimulates local inflammation, thereby initiating the tendon healing process. The proposed treatment is based on the understanding that the degenerative process is marked by a lack of inflammation. This contrasts with the common misconception that inflammation is always detrimental.
- Increase Blood Flow: The massage increases blood flow to the injured region, which boosts healing.
- Break Down Scar Tissue: Deep tissue massage can also be used to treat tennis elbow. There is almost always a little bit of scar tissue from the overuse of the muscles and tendons that cause the pain of tennis elbow.
A randomized clinical trial was conducted to compare outcomes after recruitment of consecutive patients presenting with lateral epicondylitis. Patients were randomized to receive one of 3 treatments: group 1: splinting and stretching, group 2: a cortisone injection, or group 3: a lidocaine injection with deep friction massage. Pretreatment and posttreatment parameters of visual analog scale (VAS) pain ratings, Disabilities of the Arm, Shoulder and Hand (DASH) scores, and grip strength were measured.
At 6-month follow-up, only patients in the deep friction massage group demonstrated a significant improvement in all outcome measures, including VAS pain score, DASH score, and grip strength. The results of this study demonstrate that deep friction massage has a lasting therapeutic effect at the 6-month follow-up, whereas splinting or cortisone injection demonstrated early benefit without a lasting effect. In addition, deep friction massage might be beneficial in patients who have failed cortisone injection(s) or who do not want to have cortisone.
Additional Treatment Options
While massage therapy can be highly effective, other treatment options for tennis elbow include:
- Splinting and Stretching: The control group (group 1) received a removable cock-up wrist splint to be worn full-time for 6 weeks, except for hygiene and when performing therapy. The patients in group 1 were provided with a standardized therapy protocol that started after 2 weeks of rest. The standardized therapy protocol was prescribed to all patients across the 3 groups and consisted of a supervised upper-extremity stretching program for the wrist and finger extensors and flexors, as well as range of motion exercises for the elbow, forearm, and wrist.
- Corticosteroid Injections: Group 2 received a cortisone injection of 20-mg methylprednisolone with 1% lidocaine totaling a 10-mL solution, injected into the area of maximal tenderness. Patients then wore a removable cock-up wrist splint for 3 to 5 days with instructions to start the stretching and reconditioning protocol once the injection pain subsided after 1 to 2 weeks of rest.
- Physical Therapy: Physical therapy, in particular, may involve a combination of methods such as muscle-stimulation techniques, massage, manual therapy, and exercise. Having a comprehensive assessment by the physical therapists can be of tremendous value in helping you understand the role that your daily routine and activities may be playing in regard to your tennis elbow. They can complete a detailed biomechanical and postural exam, and help you develop healthy motor patterns again by designing a specific program to restore the function and mobility of your elbow.
Simple Self-Care Exercises
Here are some examples of exercises that the physical therapists may suggest to help prevent or improve tennis elbow. Be sure to contact a physical therapist or doctor before undertaking any exercise activities to ensure appropriate activities for your condition or level of activity.
- Eccentric Wrist Extension Exercise: This involves using a light dumbbell, water bottle, or can of food, sitting in a chair that has an armrest, and resting the forearm on the armrest while holding the weight with the palm faced down. Lift the wrist up and then slowly return it to the resting position. Try this exercise 3 to 4 times per week, 3 sets of 10 reps (or to forearm fatigue), for at least 6 weeks. These must be done pain free.
- Eccentric Wrist Flexor Exercise: Similarly, this exercise involves holding a dumbbell or a can of food, sitting in a chair and placing the forearm flat on the thigh with the hand holding the weight facing upward. Let the wrist bend backward slowly and then bend the wrist upward again. Repeat this movement 10 times and perform it 3 times, every other day for at least 6 weeks.
- Forearm Flexor and Extensor Stretches: These stretches improve blood flow to the injured region, which boosts healing. They entail holding out the affected arm, parallel to the floor and bending the wrist up or down with the elbow straight and applying a gentle pull to the bent wrist and hand to stretch the forearm. Hold these stretches for 30 seconds, and repeat them 2-3 times per day, particularly if you work at a computer or are very active in sport.
- Tricep Stretch: This stretch helps improve recovery by decreasing mobility problems and stiffness that may develop while resting the elbow. It entails bending the arm backward, behind the back, while mimicking scratching the back. Use the unaffected arm to gently press the elbow backward until non-painful stretching is felt.
Prevention Strategies
There are two things you can do to prevent tennis elbow. If you do something that involves a lot of repetitive motions, work on strengthening your arms. Small workouts with low weight will help you build and condition the muscles that contribute to tennis elbow. The second step is even more important. If you’ve overused your forearms in any way, give yourself enough time to cool down and heal before you resume your normal activity. Always wait before increasing the intensity of any activities that utilize these muscles - graduate to harder levels slowly. Staying hydrated and eating plenty of protein can help your muscles heal in a timely manner.