Tennis-Elbow-Diagram-400Amy Carr of TimeOut Chicago magazine came in a few years ago for a treatment. She's a tennis player, and wanted help with a persistent pain issue that had been bothering her for almost a year. Her pain was diagnosed as tennis elbow, or lateral epicondylitis, and she had seen several practitioners since the previous March without getting much relief.

Her report on our session appeared in the Feb. 5, 2009 issue of TimeOut Chicago, and to quote an excerpt, "Combining his knowledge of anatomy and Western medicine with Thai massage techniques, Duff gives my aching tennis elbow more relief than a year of cortisone shots and chiropractic visits..." Which is flattering, but in truth, cases like this are relatively easy to address by anyone with the right training.

It's all about your worldview. Allopathic western practitioners almost invariably assume that pain near a joint (for example, elbow, knee, lumbar vertebrae) is due to injury, dysfunction in the joint, or a mysterious onset of inflammation (tendonitis) in the tendons and ligaments that cross the joint. A quick Google search of tennis elbow will find thousands of pages all explaining what the "injury" of tennis elbow is all about. This often mistaken attitude about joint pain is what leads to the 3 common and frequently ineffective therapies that we hear in a litany from our clients: anti-inflammatory medications, cortisone shots and surgery. Unfortunately, many are still being told to ice their elbow, which is the worst possible strategy. While we consider our western medical system to be firmly based in science, one wonders what scientific reasoning is at work in the face of a great deal of evidence that these approaches usually don't work to actually relieve pain.

...Duff gives my aching tennis elbow more relief than a year of cortisone shots and chiropractic visits... Amy Carr, Editor, TimeOut Chicago

A Different View of Pain: Trigger Points Simulating The Pain of Tissue Injury

Supinator muscle trigger point referral and anatomy

Referral patterns from trigger points in the supinator muscle include lateral epicondylar pain.

A simple but profound paradigm shift is what makes cases like this easy to solve. The key is that muscle tissues themselves are most often the source of at least some of the pain, if not all of it -- but mostly because they have trigger points in them, not because there is actual tissue damage. Of course, tissue damage is possible - it just isn't the most statistically likely explanation for the pain.

Trigger points can be resolved with a variety of relatively non-invasive techniques, and are not helped in any permanent way by wearing braces, ace bandages, anti-inflammatory drugs, cortisone injections or surgery. If anything, these approaches are likely to make the problem worse.

Dr. Travell (and many researchers before her) discovered that tender points in muscles can cause referred pain -- pain that is felt 90% of the time in parts of the body distant from the tender point itself. Often the pain can be quite severe and feel like it's around or deep within a joint. So it's not surprising that many practitioners are fooled into assuming that structural damage to the joint itself is causing the pain. One of the mantras we use is "don't chase the pain" -- in other words, the pain is usually not where the problem is.

Of course, when we do need surgical repair, western medicine is brilliant -- and I do not intend in any way to underestimate the incredible skill and sophistication of modern medicine when it is appropriately applied. The problem comes from our allopathic injury-centric model, which assumes that all pain must derive from injury or degeneration within joints, nerves or connective tissues. Sometimes joints do need repair. Many times joints may show some evidence of arthritis, degeneration or injury, and the surgery fails to resolve the pain. This is because nobody treated the tender points and taut fibers in muscles that refer pain there.

Treating the Muscles That Refer Pain to the Lateral Epicondyle

Numerous muscles refer pain to the area of the lateral epicondyle (the outside of your elbow area if your arm hangs down by your side with your thumb pointing away from the midline). As trigger point therapists, our first approach to treating tennis elbow is to identify and check those muscles for taut fibers and tenderness, and treat any problems that we find using compression and motion to bring the muscle short and into stretch. The list of likely offenders for tennis elbow includes:

  • Supinator
  • Extensors of the Hand
  • Extensors of the Fingers
  • Brachioradialis
  • Triceps
  • Scalenes (a potential key/satellite relationship)

The supinator is a major actor in stabilizing the racquet head each time the ball is hit during tennis. Racquets with large heads allow for off-center hits, and the supinator is recruited to forcefully stabilize the forearm against pronation. If this muscle gets acutely or chronically overloaded, it develops a point of local metabolic stagnation (trigger point) that sends pain to the outside of the elbow joint -- however the pain can only be addressed by treating the supinator muscle itself.

Using heel pressure on the supinator and forearm flexors.

Using heel pressure on the supinator and forearm flexors. The extensors receive compression from the mat below.

We cover detailed treatment of these muscles in our CTB for Elbow, Forearm and Hand Pain workshop. We treat the supinator with flat compression between the proximal radius and ulna, point stimulation, and post-isometric relaxation. In Amy's case, I used our standard protocol for this region, which assessed and treated not only the muscles listed above that cause immediate referral, but the other muscles (particularly in the shoulder) that can cause satellite referral by getting the more local muscles into trouble.

We always examine range and quality of motion in the joints near the area, and our goal is to restore normal, pain-free movement. Following this sort of rigorous protocol, the vast majority of time we're successful in restoring movement without pain. Of course, unless the patient ultimately addresses perpetuating factors, such as swing mechanics, lack of conditioning, breathing dysfunction and a host of other considerations, our work will have to be repeated on a regular basis. I always approach bodywork as an educational process, and my goal is to get the patient independent of me and healthy as quickly as possible.

Conversely, if the pain was truly the result of a tear or injury, our bodywork efforts would not make a difference in the pain.

Ironically, Drs. Travell and Simons' incredible body of work is not commonly given much attention in medical or other professional schools -- this truly is the Great Mystery to me. Consequently, millions of patients each year with myofascially-induced pain are prescribed anti-inflammatories, given cortisone shots and unnecessary surgeries, only to find that their pain is still around, or worse (at which point it is called "intractable"). Some of them eventually find their way to our clinic, often prepared for another failure. Fortunately, that rarely happens.

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