www.amtamassage.org/mtj 15

For this reason, “Over time, time, “Over with continuing with continuing the overuse, pulling constant of the common extensor tendon upon its bony will attachment lead to eventually irritation, swelling, pain and therefore the periosteum at of the lateral of the epicondyle . is a general term for condition). Tennis is so named because elbow osis is a general term for condition). Tennis means swelling); lateral epicondylosis is applied when swelling is no longer present itis means swelling); lateral epicondylosis is applied when swelling is no longer

Art Giovanni Rimasti | Photography Yanik Chauvin Yanik | Art Rimasti Muscolino Joseph E. | Photography by Giovanni

Tennis elbow is the term given to the condition that involves inflammation or degeneration Tennis of the posterior and/ of the myofascial tissue of the common extensor belly/tendon (Figure 1). or inflammation of its lateral epicondyle attachment on the humerus Tennis and the tendon begins to degenerate instead ( tennis elbow is also known as lateral epicondylitis or lateral epicondylosis. The term lateral epicondylitis is applied tennis elbow is also known as lateral epicondylitis or lateral epicondylosis. The when swelling is present ( playing tennis is often the cause of this condition.

EXPERT CONTENT EXPERT Body Mechanics 16 mtj/massage therapy journal spring 2014 an instrument,orevenamassagetherapistworkingonclients/patients. ter orothermanuallaborerholdingandswingingatool,musicianplaying tension. Otherexamplesincludeworkingatacheckoutcounter, acarpen screwdriver, holding a steering wheel, gripping a tennis racquet when hitting lead totenniselbow. Examples abound:grippingatoolsuchaswrenchor (Figure 3).Therefore,extended periods oftimespentgrippinganobjectcan the distaltendonofextensor carpiradialisbreviscontractandtauten lateral/radial tothemidlinewhen makingafist,youcanusuallyseeandfeel carpi radialisbrevis.Ifyouobserveandpalpatetheposterior wristslightly The musclethatismostcommonlyengagedforthisfunction istheextensor flexing, weneedtoisometricallycontractextensormusculature ofthewrist. would flexitatthewristjoint. To stabilizethewristjointandpreventit from contract toflexthefingers,theyalsocreateapullingforce onthehandthat fundus, and the flexor pollicis longus muscles. However, when these muscles fingers, weengagetheflexordigitorumsuperficialis, digitorumpro , ifextensionofthewristandfingerswereonlycausetennis elbow, thatisflexingthefingerstomakeafistor grip anobject. Toflexthe activity thatmanytherapistsdonotrealizeisamajorcontributor totennis elbow, thisconditionwouldnotoccurasoftenit does. Thereisanother be overusedandinjured. ger thantheyareusedto,themusclesandtheircommonbelly/tendonmay hits moreforcefullythantheyareusedto,and/oriftheplayerplaysforlon into flexion(Figure2b).Therefore,ifaplayerplaysagainstsomeonewho striking theracquet,whichwouldotherwisecausewristjointtocollapse metrically tostabilizethehandatwristjointagainstforceofball wrist extension.Butinsteadofcontractingconcentrically, theycontractiso position whenstrikingtheballstillrequirescontractionofmuscles still possibletodeveloptenniselbowbecausemaintaininganeutralwrist even iftheplayermaintainshandinproperneutralposition,itis musculature of the common extensor belly/tendon (Figure 2a). However, centric contractionofthewristextensormusclesandthereforestresses stead extendsthehandatwristjointduringstroke, it requirescon in neutralposition and not extend. If someone has improper formandin stroke thatisinvolved.Whenhittingthisstroke,thewristjointshouldstay this condition. and activitiesthatengagewristfingerextensioncanpotentiallycause carpophalangeal andinterphalangealjoints.Therefore,excessivepostures of thehandatwristjointaswellextensionfingersmeta dent intheirnames,thesemusclescreateextension,specificallyextension extensor digitiminimi,andthecarpiulnaris(seeFigure1).Asevi These musclesaretheextensorcarpiradialisbrevis,digitorum, fore thetermcommonextensorbelly/tendonisactuallymoreappropriate.) but theassociatedmusclebelliesalsousuallyblendintooneanother, there sor tendon because the tendons of these muscles blend into one another, tendon. (Note:Itiscommontoreferthisstructureasthe any overuseofthemusclesthatcontributetocommonextensorbelly/ play tennistohavethiscondition.Effectively, thecauseoftenniselbowis Even thoughplayingtenniscancauseelbow, itisnotnecessaryto CAUSES However Of course,tennisisnottheonlyactivitythatrequiresfingerandwristex If playingtennisisthecauseofelbow , itisusuallythebackhand common exten------Edition. 2010.Elsevier. musculature. extensor contraction ofthewrist isometric joint straight thestroke during requires musculature.extensor B, Holdingthe wrist concentric contraction ofthewrist jointthestrokewrist during requires muscles. the extensor A,Extending tennis requires contraction ofthewrist The Skeletal MusclesoftheHumanBody, 3 Muscolino, JETheMuscularSystem Manual – view oftherightforearm. Modeledfrom attachment onthehumerus. Posterior belly/tendon anditslateral epicondyle myofascial tissueofthecommon extensor FIGURE 2 FIGURE 1 Tennis elbow involves the (B) (A) Hitting a backhand stroke in a backhand Hitting Extensor carpiulnaris Extensor digitiminimi Extensor digitorum brevis Extensor carpiradialis belly/tendon Common extensor Lateral epicondyle rd

www.amtamassage.org/mtj 17 - - - - Edition. 2010. Elsevier. Edition. nd In If tennis elbow is left unresolved B tion, in addition to pain, swelling is also usually present at the common extensor belly/tendon and can often be felt on palpatory examination. swelling can also spread to theThe lateral epicondyle, which is often vis ible; look for the bony contours of the lateral elbow to be less evident com pared to the other side of the client’s In later stages of this condition, body. usually after a period of six months or swelling gradually recedesthe more, and degeneration of the collagen con- struct of the common tendon begins As this transition in patho- to occur. physiology occurs, the description of as previouslythis condition changes, mentioned, from lateral epicondylitis to lateral epicondylosis. Due to the degeneration of the tendon and the continued pull of muscular contrac- tion, tearing of the tendon may also occur (Figure 4). for a very long time, because its un derlying cause is overuse and irrita- tion of the extensor musculature of the posterior forearm, tendinitis of the distal tendons of these muscles conse- possible a is joint wrist the at quence. of thiscondi stages early the - - - - Finger flexors ECRB Gripping an object requires stabilization of the at the wrist joint, usually by the extensor carpi radialis brevis (ECRB). A, (ECRB). the extensor brevis carpi the wrist usually by of the hand at joint, radialis stabilization Gripping an object requires Over time, with continuing overuse, the constant pulling of the common In addition to repeated microtraumatic overuse of the muscles of the In addition to repeated microtraumatic SIGNS AND SYMPTOMS AND SIGNS FIGURE 3 3 FIGURE ic and severe. extensor tendon upon its bony attachment will eventually lead to irritation, swelling, and therefore pain at the periosteum of the lateral epicondyle of the humerus. Therefore, even though this condition is technically named for the lateral epicondylar attachment, pain at the lateral epicondyle itself does not usually occur until this condition has progressed to be more chron

mon extensor belly/tendon or the lateral epicondyle of the humerus, such lateral epicondyle of or the extensor belly/tendon mon musculature associated of the powerful overstretch or sudden fall, a bang, as can also contribute to tennis elbow. elbow are pain at the common ex The most common symptoms of tennis associated muscles. This tightness tensor belly/tendon and tightness of the mus- associated the of bellies or belly entire the of tightness global be might points. The pain will usually oc cles, or might manifest as myofascial trigger muscles, whether it is concentric or cur with contraction of the associated eccentric contraction during motion, or isometric stabilization contraction. Pain as well as tightness will also be evident with palpation of the proximal common extensor proximal and their musculature the associated of bellies tendon. Pain might also occur when the muscles of the common extensor tendon are stretched; this would occur when the and/or fingers are actively or passively moved into flexion. If the tightness of the musculature of the common extensor tendon is sufficient, it might also cause decreased active or passive flexion range of motion of the wrist joint. Due to its role in stabilization of the wrist joint, the most commonly affected muscle with tennis elbow is the extensor carpi radialis brevis. common extensor belly/tendon, a direct physical macrotrauma to the com common extensor belly/tendon, a direct a backhand or forehand, gripping a pen or pencil when writing, or simply a backhand or forehand, gripping a pen we hold/grip objects, it is easy to see holding a cell phone. Given how often why tennis elbow is such a common condition. A contraction of the extensor carpi radialis brevis can be seen when the fingers flex to hold an object. B, contraction of the ECRB can be seen to hold an object. B, be seen when the fingers flex can of the extensorcontraction brevis carpi radialis 2 System, Kinesiology Neumann, DA of the Musculoskeletal 3A is modeled from when making a fist. Figure 18 mtj/massage therapy journal spring 2014 fingers. to stabilize whenflexingthe thewrist wrist. Therefore, itisthebestchoice crosses farfrom thecenter ofthe brevis neithermoves thefingersnor created. radialisThe carpi extensor motion that eachofthemwould have cancel outtheunwanted frontal plane engagement ofanothermuscleto that ulnaris) wouldcarpi thenrequire and ulnardeviation for the extensor for radialis carpi longus theextensor frontal (radial deviation planeaction it would have created anunwanted of thesemuscleshadbeenchosen, far to theulnarside. Therefore, ifeither crosses ulnaris carpi side; theextensor radialis longuscrosses farto theradial center ofthewrist. The carpi extensor in otherwords, theycross farfrom the from thefrontal planeaxisofmotion; However, theycross joint thewrist far they donotcausefingerextension. attach distallyonthemetacarpals, so ulnaris carpi longus andextensor candidates. radialisThe carpi extensor scenario; therefore theyare notgood which isthedesired inthis joint action chosen, itwould opposefingerflexion, Therefore, ifeitherofthemwere aswell extensors.extensors aswrist digitorumhe extensor and digiti minimiareextensor finger ulnaris. carpi extensor radialis carpi longus,extensor and digitorum, digiti minimi, extensor the wrist. They are theextensor could potentially beusedto stabilize other four musclesthat extensor wrist becomes clearwhenwe lookat the joint.wrist The answer to thisquestion flexionandtherebywrist stabilize the that could extension preventof wrist musclecould createextensor aforce in thisscenario? After all, any wrist radialiscarpi brevis asthestabilizer system choosetheextensor nervous make afist.Butwhy doesthe central or the fingers to hold/grip anobject jointwrist whentheycontract to flex muscles from flexingthehand at the isneededto preventextensor these joint, therefore stabilization by awrist The longfingerflexors wrist cross the Brevis?Radialis CarpiExtensor Why the T most likely condition that needs to be differentially assessed is the pres - Tennis elbow isafairlysimpleandstraight-forwardconditiontoassess.The tearing ofthecommonextensortendon. accurate way to assess/diagnosethe extent of possible degeneration and/or would alsolikelyelicitpain. epicondyle, andthetightnessofassociatedmusculature,localpalpation the common extensor tendon, and the irritation and swelling of the lateral show positiveforpain.Giventheirritation,swelling,anddegenerationof carpi radialis brevis is most often affected, active radial deviation may also fected musclesareneithercontractednorstretched.Becausetheextensor extension ofthehandorfingersisusuallynegativetopainbecauseaf common extensortendonandthelateralepicondyle(Figure5C).Passive because it stretches the associated musculature and therefore pulls on the Active orpassiveflexionofthewristfingerswouldalsolikelyelicitpain extensor belly/tendonandlateralepicondyleofthehumerus(Figure5AB). because theassociatedmusculaturecontractsandpullsoncommon at themetacarpophalangealandinterphalangealjointswilllikelycausepain manual resistancetoextensionofthehandatwristjointorfingers the underlyingpathomechanicsofcondition.Activerangemotionor Knowing howtoassesstenniselbowisanextensionofourunderstanding the tendon. Tears (seeninthefigure as white areas) may alsooccur withinthe tendon. FIGURE 4 Chronic tennis elbow usually results indegeneration ofthecollagen of structure DIFFERENTIAL ASSESSMENT ASSESSMENT Medically , tenniselbowisusuallydiagnosedviaultrasound.Thisan - www.amtamassage.org/mtj 19 Assessment of tennis elbow. A, Active extension of the hand and fingers. B, extension of the hand and fingers. A, Active elbow. of tennis Assessment FIGURE 5 FIGURE Manual resistance to extension of the hand. C, Active flexion of the hand and fingers. flexion of the hand and fingers. C, Active extension to of the hand. Manual resistance ------Begin with mild to moderate pres The only other condition that MANUAL TREATMENT MANUAL sure fascial spreading strokes to the entire forearm with concentration forearm. posterior the proximal on Longitudinal strokes to the poste- rior forearm are performed proxi with your pressure mally to distally, decreasing as the muscles transition from bellies to tendons. Cross fiber com- the on be focused should work

Tennis elbow is primarily caused by Tennis overuse and tension of the muscles of the common extensor tendon, therefore treatment should be di- rected to their myofascial tissue. A good protocol to follow involves fascial spreading, longitudinal and cross fiber strokes, and pin and stretch to the posterior forearm. Be cause these muscles cross the wrist, carpal of the mobilization joint bones may also be beneficial. ticulation with the humerus at the elbow joint or with the ulna at the proximal radioulnar joint. However, dysfunction of the radial head does not commonly occur and would not show positive during physical exam ination with contraction or stretch ing of the musculature of the com mon extensor tendon. might be confused with tennis el- bow is dysfunction of the head of the radius, whether it is with its ar lies of the common extensor mus common extensor lies of the the presence of these cles. However, be considered to be could also TrPs and consequent part of the overuse extensor tightness of the common a part of musculature, and therefore Wrist tendinitis tennis elbow itself. common ex of the muscles of the show posi- tensor tendon will likely and passive tive for the same active the predomi ranges of motion, but at be will pain the of location nant the wrist region instead of the elbow. ence of myofascial TrPs in the bel the in TrPs of myofascial ence 20 mtj/massage therapy journal spring 2014 extensor myofascitisextensor . the bony attachment site. Given thecausative mechanismofthe tennis elbow, abetter perhaps namewould be the myofascial overuse ofthis condition would place sufficient physical stressactual pain upontheepicondyle at tocause of thecommon tendon would thenexhibitpainandtenderness. allowed If to progress, itwould onlybemuchlater that assessed astennis elbow, would by likelybemarked tightness ofthemusculature. With continuing overuse, thefascialtissue thisregard, belly/tendon.the musclesofcommon In extensor stageoftennis theearly elbow, before itwould even be but unlessthelateral epicondyle isinflameddue trauma,to direct lateral epicondylitis begins asan overuse condition of tissueoftheepicondyle tissueinflammation eventhat because itistheperiosteum is inflammed), soft thisissoft (actually istruethat tissue.once thisconditionupon soft It isfarenoughadvanced, there willbeinflammation ofthelateral epicondyle of the condition. This shows the bias that Western has for Medicine hard bony tissue and the lack of emphasisthat it places bony epicondylar attachment of the associated musculature and not for the myofascial tissue that is the true progenitorsoft isinterestingIt to note that thetechnical namefor tennis elbow, lateral epicondylitis, isnamedfor theinflammation ofthe What’s inaname? part ofthecare. is desired,icewouldnotbeusedas lagen fibers.Becauseinflammation ing processofthedegeneratedcol into theregiontofacilitateheal tion sothatfibroblastsaredrawn work istoactuallycreateinflamma Technique. The purposeofthisdeep brand oftoolsiscalledGraston use oftools.Onetechniqueand cross fiberpressure,oftenwiththe apists advocateextremelystrong , iftheconditionhas ment approachchanges.Somether phase of epicondylosis, the treat- entered thechronicdegenerative as aresultofthesofttissuework. done tominimizepossibleswelling cial aftersofttissuemanipulationis deeper work.Icingisalsobenefi decrease sensitivityandallowfor before softtissuemanipulationto the area is tender, icing can be done when inflammationispresent.If treatment protocolfortenniselbow ing isalsoanimportantpartofthe that inflammation isincreased.Ic be deep,butshouldnotsodeep epicondylitis, depthofpressurecan the clientispresentingwithlateral the lateralepicondyle(Figure6).If mon extensor tendon tissue near For both However epicondylitis and epi ------farther distallydowntheposteriorforearm. repetition of pin and stretch should move the point of sustained pressure extensor musculature,therebyallowingforabetterstretch.Eachsuccessive the stretchbyaddinganeuralcomponentthatinhibits/relaxestarget the reciprocalinhibitionreflexisinitiated.Thisincreasesefficacyof of pressureandthewrist.Ifclient’s flexionmotionisperformedactively, the attachmentthatmoves;inotherwords,betweenpointofapplication region of musculature that is between the pinned point of the muscle and flexed (Figure7).Thistechniquemechanicallyfocusesthestretchon on themusculatureasclient’s handandfingersarepassivelyoractively condylosis, pinandstretchcanbeperformedbyholdingsustainedpressure movement patternsthatmaycontributetoandperpetuatethetenniselbow. sible fortenniselbow, theymaybeinvolvedindysfunctionalposturaland anterior forearm,andhand.Althoughtheseregionsarenotdirectlyrespon neck, andworkyourwaydownintotheupperback,shoulderregion,, done, itiswisetoworktheentireupperquadrantonthatside.Beginat FIGURE 6 Once directcaretotheposteriorforearm/wrist/handregionhasbeen Cross fiberstrokes to the tendon. common extensor common - www.amtamassage.org/mtj 21 Epicondylitis or Epicondylitis Epicondylosis? in is acute, elbow tennis When has lateral the client other words, it is primarily a condition epicondylitis, is care Therefore, of inflammation. the cause and removing at directed For the inflammation. decreasing is often included ice this reason, as part regimen. the treatment of elbow, tennis with chronic However, epicondylosis, lateral in other words, is past. the inflammatory process the removing beyond Therefore, care initial cause of the condition, blood increasing toward is oriented region to the and inflammation flow into can be drawn fibroblasts so that the mend and repair to the region In collagen. cases, these degenerated and is contraindicated the use of ice very creating at aimed deep work is indicated. inflammation do not magically conditions However, like chronic to acute change from there flipping a switch. Rather, time during which is a transition and of both epicondylitis attributes means This present. are epicondylosis is still experiencing the client that but is also some inflammation of degeneration have to beginning matrix of the common the collagen difficultyThe arises extensor tendon. during presents when the client In cases, these time. this transition be made whether a decision has to regimen the treatment approach to or has epicondylitis as if the client Makingepicondylosis. this decision One approach can be challenging. with one approach begin can be to in this manner the client and treat If no weeks. three for twice a week then try has occurred, improvement a more Ofthe other approach. course, if an direction is afforded definitive the so that has been done ultrasound is exact of the pathomechanics state understood.

Pin and stretch of the extensor musculature of the forearm. A, Performed A, Performed of the forearm. of the extensor musculature and stretch Pin FOR TENNIS TENNIS FOR ELBOW PRECAUTIONS/CONTRAINDICATIONS SUMMARY OF MANUAL TREATMENT PROTOCOL PROTOCOL TREATMENT MANUAL OF SUMMARY FIGURE 7 FIGURE When working on a client who has tennis elbow, be aware that very deep When working on a client who has tennis elbow, pressure may translate to the radial nerve. The radial nerve passes into the ex- common the of musculature the to deep side, posterior the on forearm tensor tendon. 1. Fascial spreading strokes to the forearm 2. Longitudinal strokes to the posterior forearm 3. Cross fiber work to the common extensor tendon 4. Pin and stretch to the posterior forearm 5. Ice the common extensor belly/tendon 6. Joint mobilization of the carpals entire upper quadrant on that side 7. Work passively. B, Performed actively. Performed B, passively. 22 mtj/massage therapy journal spring 2014 as well as mend tears. mend tears. as well as tissue collagen remove degenerated done to may be surgery scenarios, In worst-case beneficial. very be can (PRP) injections plasma rich platelet including apy injections, prolother present, is epicondylosis lateral of phase degenerative the If injections. cortisone as well as sone, corti as such medication matory anti-inflam steroidal prescription involves usually epicondylitis eral for lat management Medical ered. consid be should aphysician to ral refer not successful, is care therapy manual conservative Whenever be recommended. forearm/hand musculature should have resolved,strengtheningthe signs andsymptomsofthecondition tion iscontraindicated.Ifandwhen ing andanti-inflammatorymedica has progressedtoepicondylosis,ic- matory medication.Ifthecondition take over-the-counter anti-inflam- be done;clientsmayalsochooseto flammation ispresent,icingshould stretching should be avoided). If in- are present,inwhichcasevigorous less common extensor tendon tears into flexionshouldbedone(un stretching of the hand and fingers for long periods of time. Frequent fingers andholding/grippingobjects extension activitiesofthehandand foremost among these are repetitive and activities as much as possible; advised toavoidoffendingpostures tennis elbow. The client should be tant aspectofthetreatmentfor Self-care isanextremelyimpor MEDICAL APPROACH SELF-CARE FOR THE CLIENT Science ofKinesiology. overseas. Visit Joseph’s websiteatwww.learnmuscles.com orhisprofessionalfacebookpage: TheArtand Education ClinicalOrthopedicManual Therapy(COMT)certificationworkshopsaroundthecountry and and AdvancedTreatment Techniques fortheManual Therapist:Neck(LWW). JosephteachesContinuing including TheMuscleandBonePalpationManual, TheMuscularSystemManualandKinesiology(Elsevier) currently teachesanatomyandphysiology atPurchaseCollege,SUNY. Heistheauthorofmultipletextbooks soft tissuemanipulationinhispractice.Hehasbeenamassage educator formorethan25yearsand Joseph E.Muscolino,DC,isachiropractorinprivatepractice Stamford,CTwhoemploysextensive n ------orthopedic massageonce eachmonth. ortwice orthopedic remaining symptoms. For proactive self-care, Glenncontinues to receive clinical Care was continued at once perweek for anothersixweeks to remedy the At theendofsix weeks, Glenn’s symptoms hadabated approximately 80percent. to grip it. including usingawiderpenthat hasarubbergrip sothat lessstrength isneeded He was also given recommendations to avoid overuse of his forearm muscles, extremity. includingstretching Glennwas given instructions andice. self-care stretching, upper work, andleft andjointneck, mobilization to theupperback, to theanterior forearm, andshoulderregion; arm andmoistheat, deeptissue therestwas spent ofGlenn’s working right upper quadrant withdeeptissuework to reduce possible inflammation as a result of the work. The remainder of the time deep cross fiber work belly/tendon.to the Icecommon extensor was thenapplied by 20-30minutes ofdeeptissuework to therightforearm, includingmoderate to session consisted ofapproximately five minutes of myofascial spreading, followed massagesperweek forrecommended four two one-hour to sixweeks. Each assessment oflateral epicondylitis tennis elbow was made. The therapist Given the results of the assessment tests and the presence of swelling, an theseconditions testedneck; negative. assessment tests for lesions in the thoracic outlet syndrome and space-occupying tendon andthelateral epicondyle ofthehumerus. The therapist alsoperformed pain were inflammation andpalpatory also Mild found at the common extensor elicited pain.Palpation at bellyrevealed thecommon extensor tightness andpain. was asymptomatic.extension Active radial deviation against resistance also tendon, asdidpassive flexionandmanual resistance passive to extension; joint.wrist Active produced flexion and extension pain at the common extensor andpassive active rangeThe ofmotionthehandat therapistthe performed seek care andwent work. to amassagetherapist whodoesclinicalorthopedic holding thesteering wheelofhiscarto drive Glennfinallydecided toto work. pen to grade papers. thepastfew In weeks, hehaseven experienced painwhen school year hasprogressed. Heespeciallynotices thepainwhengripping the forearm pain near his elbow. The pain has been getting steadily worse as the Glenn isahighschoolEnglishteacher. thepastyear, Over hehasnoticed right Case study: