How to perform sports massage for tennis elbow injuries

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Tennis elbow is extremely common in sport. Massage can help relieve it. This article features tips to help you perform massage for tennis elbow injuries.

Tennis elbow is the most common overuse injury of the elbow. One that massage therapists are likely to come across regularly. One way to help is using massage for tennis elbow. In this article, adapted from Sports Massage for Injury Care we’ll provide details of how to diagnose, assess and treat tennis elbow injuries using massage techniques.

What is tennis elbow?

Tennis elbow, or lateral epicondylitis, is a common condition that causes pain around the outside of the elbow. It is the result of repetitive strain to common extensor tendons of the wrist. As the name suggests, it’s most commonly seen in tennis players. However, tennis elbow can occur during other activities that involve repetitive stress on the wrist extensors.

Tennis elbow symptoms

Tennis elbow is characterised by a deep ache at the lateral epicondyle that’s made worse by activity. Other symptoms may include:

Pain to the lateral elbow
Mild to moderate swelling
Limitation of wrist extension or flexion

Athletes may also experience sudden twinges of severe pain. In extreme cases, sharp pain is sometimes reported when gripping a racquet or even shaking hands.

Typical History

Tennis elbow, like most overuse injuries, develops gradually over a few months. It might flare up suddenly as a result of increased intensity of activity, like competing in a tennis tournament. If the injury isn’t the result of a racquet sport, look for repetitive motion in the client’s daily activities.

Relevant Anatomy

In most cases, the primary injury is tendinopathy of the extensor carpi radialis brevis (ECRB) tendon, just distal to its attachment on the lateral epicondyle. The rest of the wrist and finger extensors may be affected by the presence of tennis elbow, either by becoming hypertonic or by becoming inhibited because of pain. See figure 7.12a and 7.12b for illustrations indicating the wrist and finger extensors.

Sports Massage for Injury Care features a more in-depth look at the makeup of these muscles.

Assessment

You can assess tennis elbow injuries using a variety of methods. These include observation, range of motion (ROM) and manual resistive tests. When assessing and treating tennis elbow, it’s important to avoid palpatory or massage techniques that irritate the radial nerve.

Observation

In severe cases, swelling over the lateral epicondyle may be present.

ROM assessment

Active motion at the wrist consists of flexion, extension, abduction and adduction. Depending on the severity of the injury, these motions may cuase pain. Passive motion is generally pain-free except for wrist flexion. When the elbow is extended, this may stretch painful tissues on the extensor side of the forearm.

Resisted extension of the wrist is painful. Resisted radial deviation may also be painful.

Manual resistive tests

The athlete, sitting or standing, places their wrist in neutral, forearm pronated. The examiner then grasps the lateral elbow with one hand. The other hand provides resistance as the athlete attempts to extend the wrist (see Figure 7.13a and 7.13b).

Assessing massage for tennis elbow injuries — Figure 7.13a Resisted wrist extension test with elbow flexed

The isometric contraction should begin slowly. Then build it to a strong engagement of the target muscles. With the elbow flexed, the test will engage the ECR brevis more fully. With the elbow extended, the test will focus more on the ECR longus. Pain or weakness is a positive finding. Resisted extension of the middle finger is commonly positive for pain or weakness in tennis elbow (Fairbank and Corlett, 2002) (see Figure 7.14). If there isn’t any pain, the examination should be widened to include the other muscles that might cause lateral epicondyle pain, such as the supinator, brachioradialis and anconeus.

Figure 7.14 Middle-finger extension test

Palpation

Palpation over the lateral epicondyle should be done from the side, rather than from the top. This helps avoid pressing into the brachioradialis, the supinator and the radial nerve. Tenderness may be reported at the common extensor origin on the lateral epicondyle, the myotendinous junction of ECR brevis and the origin of ECR longus on the supracondylar ridge. The site of maximal tenderness should correspond to the findings of the manual resistive tests.

Perpetuating factors

In racquet sports, poor form is the main factor that contributes to tennis elbow. Poor form can result from inadequate conditioning that leads to fatigue of the torso and shoulder muscles. This puts additional stress on the forearm extensor muscles. Other factors that should be investigated include biomechanical imbalances, scapular dyskinesis, repetitive motion, trigger points in associated muscles and radial nerve entrapment.

Massage for tennis elbow treatment plan

Deep transverse friction is the centrepiece of treatment for tennis elbow. It also includes soft tissue work on associated muscles that may contribute to the symptoms.

We’ve outlined a typical treatment session below.

Firstly, apply compressive effleurage (massage with a circular stroking movement), petrissage (massage that involves kneading the body) and broad cross-fibre work to the muscles of the forearm and upper arm. This is used as a general warm-up and reduces the hypertonicity of the muscles.
Secondly, administer facilitated stretching of the wrist extensors.
Include more focused work to the centre of the muscle connected to the affected tendon. The application of longitudinal stripping and pin-and-stretch strokes will further enhance the pliability of the muscles and reduce tensile stress on the tendon attachment.
Then administer deep transverse friction (DTF) to the affected tendon transverse to the tendon fibre attachment direction (see figures 7.15, 7.16). The initial application of DTF should last a minute using moderate pressure. To begin with, this may be a little painful for the athlete. You should adjust the pressure to keep the discomfort at about 6/10 on the pain scale. Near the end of the first minute, any discomfort will have lessened significantly.

Using massage for tennis elbow injuries — Figure 7.15 The path of the ECR longus causes its tendon to attach transversely on the humerus, so DTF is applied in a superior-inferior direction proximal to the supracondylar ridge

After the first minute of DTF, the focus shifts to a more general massage for the upper extremity and shoulder girdle.
Return to the affected area for another round of DTF. This time, the duration of treatment may be up to 3 minutes. But only if the level of discomfort is at or below a 6 on a 10-point scale.
Then administer pain-free isolytic contractions to help reduce protective inhibition and help the muscles return to full activation.
Finish the treatment with another round of facilitated stretching for the extensor muscles. Following treatment, ice is important to help control pain.
If possible, treatment should be given every other day. Following the first session, the friction portion of the following sessions can be longer (up to 9 minutes in total) but still given in two or three doses per session. Each dose should be given long enough for the pain to subside to near zero.
Finally, the total duration of treatment depends on the severity of the injury, the frequency of treatment and the athlete’s self-care activities.

Self-care options

If any perpetuating factors are noted, these must be modified or eliminated to ensure that injury doesn’t reoccur. Once the tendinopathy pain is eliminated, initiate a programme of flexibility and progressive strengthening.

Exercise and flexibility plan

To fully rehabilitate the muscles and tendons around the elbow, strengthening and flexibility work must begin when the client is pain-free and before they return to the activity that caused the injury. Because tendons gain strength more slowly than muscles do, weight or resistance training should begin with minimal weight or resistance and high repetitions. Strengthening should be done in all ranges of motion at the forearm and wrist, with special attention given to eccentric exercise. A regular programme of facilitated stretching is also useful in maintaining maximum ROM.