by Sharon Sauer, L.M.T., C.M.T.P.T.
It’s interesting that two popular recreational sports, tennis and golf, carry a risk of overuse injury, which is felt in and around the elbow.
For almost half of all recreational tennis players, tennis elbow is anything from a nagging and persistent pain to a crippling disability. More properly known as lateral epicondylitis, tennis elbow is the baggage which goes with an otherwise wonderful outdoor sport. This pain and swelling around the outside of the elbow can be so severe the only answer is to stop playing. It also tends to affect men more than women.
While the term “tennis elbow” is the generic description for this pain and dysfunction, the same problem happens to many gardeners, bowlers, housekeepers, carpenters, mechanics and even briefcase-toting businessmen and women. It’s basically referred pain or tendonitis (depending on which muscles are involved) stemming from repetitive overloading of muscles in the forearm, upper arm and shoulder. These muscles include the supinator, the brachioradialis, the triceps brachii, the supraspinatus (part of the rotator cuff), the wrist and finger extensors, and the anconeus, a tiny muscle which helps extend the elbow. Among other actions, these muscles help anchor the arm during tennis strokes, as well as gripping or twisting the racquet. When tennis elbow is severe, the impact of a volley or overhead smash is unbearable. Pain is generally felt in or near the lateral epicondyle, whether it’s caused by true tendonitis or referred pain.
For many golfers, the sublime beauty of the sport is often marred by the debilitating pain of golfer’s elbow.
Properly known as medial epicondylitis, the pain radiating out from the inner part of the elbow can be severe enough to cause golfers to give up the game. Golfer’s elbow tends to affect men and women equally, and while it’s not as prevalent as tennis elbow, it’s just as serious for those who suffer from it.
Although “golfer’s elbow” is the generic term for this pain and dysfunction, the same problem happens to bowlers, carpenters, mechanics, baseball players (mostly pitchers) and often users of a computer mouse. It’s basically an overuse injury stemming from repetitive overloading of one or more muscles in the forearm, upper arm, shoulder, side of the torso and chest.
It’s interesting that while both tennis and golfer’s elbow entail pain in the elbow, only one of the dozen muscles which cause elbow pain contribute to both golfer’s and tennis elbow-–the triceps brachii. For golfer’s elbow, the muscles include the finger flexors, the triceps brachii, the serratus anterior and serratus posterior superior, as well as the pectoralis major and minor in the chest. These muscles serve different functions, including anchoring the arm, as well as swinging and gripping the club. Two of them are accessory breathing muscles, which when chronically contracted can cause severe referred pain. Most of these muscles are almost never recognized as being involved in golfer’s elbow.
Most medical literature focuses on the finger flexors as the primary problem muscle. This is a serious oversight, stemming largely from the fact that the pain of golfer’s elbow is generally felt in or near where the common flexor tendon attaches to the humerus near the elbow joint.
Tip of the elbow pain
Pain in the tip of the elbow can also be terribly debilitating, and it’s an entirely distinct category of elbow pain. This problem usually starts with a feeling of heightened sensitivity at the tip of the elbow, but can become so severe sufferers can’t bear to rest their elbow on a table. Tip of the elbow pain is caused by trigger points in either the triceps brachii or, believe it or not, the serratus posterior superior, which attaches to the ribs beneath the scapula and elevates ribs two through five to assist breathing. When this muscle is chronically contracted, the pain is almost intolerable.
Common remedies prescribed for either golfer’s or tennis elbow include:
- Stopping the activity causing the pain;
- RICE (rest, ice, compression and elevation);
- Using a strap or band wrapped around the forearm;
- Strengthening and stretching exercises;
- Anti-inflammatory drugs;
- Cortisone injections; or,
- Surgery (for severe cases).
Unfortunately, most of these remedies provide only partial relief at best. When people stop playing golf or tennis, they’re simply avoiding the activity which causes the pain. As soon as they resume playing, the pain usually returns. Ice, forearm bands, anti-inflammatory drugs or cortisone are temporary expedients that mask the pain for a time and allow people to play through it. In RICE, compression means using an ace bandage wrapped around the forearm, and this form of compression not only fails to address the underlying muscle problem, it also inhibits circulation of fluids to the muscle-–the opposite of what is needed.
Strengthening is an even worse remedy, because the problem is not muscle weakness. The damaged muscles do not have full range of motion, and trying to strengthen dysfunctional muscles usually causes them to shorten or contract more, exacerbating the condition the person is trying to correct. Surgery, in most cases, is an unnecessary option, chosen only because no thorough examination of all potentially dysfunctional muscles was ever conducted.
Trigger points cause elbow pain
Whether caused by tendonitis or referred pain, golfer’s or tennis elbow stems from trigger points in one or more of the muscles noted above. These trigger points must be deactivated to restore the muscles to a pain-free and fully functional condition. Fortunately, the muscles are easy to treat, and therapists can teach their patients self-care techniques to assist in recovery.
Trigger points are irritable, tight spots in taut bands of muscle tissue, which are painful when pressed, and refer pain in predictable patterns specific to each muscle.
To check for trigger points in the extensors in the right forearm, feel for a taut band of muscle just below the common flexor tendon. If you find one, press slowly into it for 10 to 15 seconds. If you’re response is “Yowie” then you’ve got trigger points in the extensors. Chronic contraction of these extensors (due to trigger points) could properly be diagnosed as tendonitis.
However, the pain can also be caused by trigger points in muscles in the upper arm, shoulder, chest, side of the torso or even the upper back. When these muscles contain trigger points, the elbow pain is caused by referred pain from these muscles, and is not properly diagnosed as tendonitis.
Fortunately, proper treatment for this condition is simple, and the problem can usually be corrected within a few weeks to three months. After you’ve checked each of the muscles for restricted range of motion and trigger points, therapy includes massage techniques, manual compression, stretching and movement to restore full range of motion to the dysfunctional muscles. Whether the condition involves true tendonitis or simply referred pain from other muscles, it can be effectively treated by myofascial trigger point therapy.
The best-kept secret
Dr. David Simons is considered a leading expert on myofascial pain and dysfunction. He co-authored, along with Dr. Janet Travell, Myofascial Pain & Dysfunction: the Trigger Point Manual (Volumes 1 and 2), one of the most comprehensive reference works in the field. Dr. Simons has stated categorically that most soft-tissue pain is caused by myofascial trigger points.
Dr. Bernard Filner, who worked with Dr. Travell for many years, says, “I’ve personally seen countless cases in which myofascial pain turned out to be the decisive element in chronic pain syndromes, such as migraine, neuropathic pain, arthritis and disc herniation. And time after time, when the myofascial pain was treated, the presenting problem was either eliminated or greatly eased in frequency and severity of symptoms.”
However, most physicians neither test for or treat trigger points in the muscles, and the referred pain caused by trigger points is largely ignored as the proximate cause of pain. The ignorance of trigger points is a sad but indisputable fact: In 2004, Dr. Simons noted that of a total of 3,601 MEDLINE citations indexed between 1996 and 2003 under low-back pain, only 17 articles (less than 1 percent) contained a reference to trigger points.
Notwithstanding this ignorance within the medical profession, increasing numbers of the general public and massage therapists are becoming aware of trigger points and referred pain. In addition, many massage schools now include an introductory course on trigger point therapy.
The National Association of Myofascial Trigger Point Therapists (www.myofascialtherapy.org) includes intensive training programs specifically for sports injuries, including elbow pain. This training represents an opportunity for all massage therapists to enhance their skill, and substantially improve patient outcomes.
Sharon Sauer is a licensed massage therapist and leading Myofascial Trigger Point Therapist with 25 years of clinical experience. Dr. David Simons calls her a “fellow pioneer in the field” for developing self-care protocols for common soft-tissue muscular pain conditions. Her company, Myo LLC, is a continuing education approved provider by the National Certification Board for Therapeutic Massage and Bodywork (NCBTMB). Sauer has trained thousands of therapists, doctors, chiropractors, dentists, nurses and massage therapists since 1993.