Manual therapy treatment:
Tennis elbow is primarily caused by overuse and tension of the muscles of the common extensor tendon, therefore massage and stretching treatment should be directed to this myofascial tissue. A good protocol to follow involves fascial spreading, longitudinal and cross fiber strokes, and pin and stretch to the posterior forearm. Because the muscles of tennis elbow cross the wrist, joint mobilization of the carpal bones may also be beneficial.
Cross fiber work to the myofascial tissue of the common extensor tendon for tennis elbow. Permission: Joseph E. Muscolino.
Begin the massage with fascial spreading strokes to the entire forearm with concentration on the proximal posterior forearm. Longitudinal massage strokes to the posterior forearm are performed proximally to distally, with your pressure decreasing as the muscles transition from bellies to tendons. Cross fiber work should be focused on the common extensor tendon near the lateral epicondyle. If the condition has entered the degenerative phase, some therapists advocate extremely strong cross fiber pressure, often with the use of tools. One technique and brand of tools is called Graston. The purpose of this deep work is to create inflammation so that fibroblasts are drawn into the region to facilitate the healing process of the degenerated collagen fibers. Pin and stretch is performed by holding sustained pressure on the musculature as the patient’s/client’s hand and fingers are actively or passively flexed. Pin and stretch technique is often employed by moving the pin (sustained compression) point of each successive repetition farther distally down the posterior forearm.
Icing is also an important part of the treatment protocol for tennis elbow when inflammation is present. If the area is tender, icing can be done before soft tissue manipulation to decrease sensitivity and allow for deeper work. Icing is also beneficial after soft tissue manipulation is done to minimize possible swelling as a result of the soft tissue work.
Once direct care to the posterior forearm/wrist/hand region has been done, it is wise to work the entire upper quadrant on that side. Begin at the neck, and work your way down into the upper back, shoulder region, arm, anterior forearm, and hand. Although these regions are not directly responsible for tennis elbow, they may be involved in dysfunctional postural and movement patterns that may contribute to tennis elbow.
Summary of Manual Therapy Treatment Protocol for Tennis Elbow
| 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 |
| 7. Work entire upper quadrant on that side |
Precautions/contraindications:
When working on a client/patient who has tennis elbow, be aware that very deep pressure may translate to the radial nerve. The radial nerve passes into the forearm on the posterior side, deep to the musculature of the common extensor tendon, so that deep pressure in this region might irritate and inflame the nerve (neuropraxis).
