37 Elbow Pain

Elbow Pain

Lateral elbow tendinopathy (LET), also known as Tennis elbow is described as pain at the outside of the elbow and in the upper forearm where the muscle tendon attaches to the bone. Medial elbow tendinopathy (MET), also known as Golfer’s elbow is described as pain at the inside of the elbow and in the upper forearm where the muscle tendon attaches to the bone.

 

Tennis Elbow/Golfers Elbow
Tennis elbow is described as pain at the outside of the elbow and Golfer’s elbow is described as pain at the inside of the elbow.

Pathophysiology

The presentation of pain in a tendon, does not always mean that the tendon itself is the primary contributor to pain. There is research that suggests a majority of nerves are found in peritendinous tissue, which is likely contributes to the complex clinical picture of tendon pain. There may be times that focal irritability (i.e., nerve irritation, trigger points, nervous system sensitization) co-exists with lateral elbow tendinopathy.

Examination

A thorough health history intake can be done to gather information about patients’ limitations, course of pain, and prognostic factors for delayed recovery (e.g., low self-efficacy, fear of movement, ineffective coping strategies, fear-avoidance, pain catastrophizing) and answers to health-related questions. Screen patients to identify those with a higher likelihood of serious pathology/red flag conditions. Then undertake a physical examination: neurological screening test, assess mobility and/or muscle strength.

Elbow Joint From Gray's Anatomy (1918)
Elbow Joint From Gray’s Anatomy (1918)

Incorporate one or more of the following outcome measurements when assessing and monitoring patient progress:

  • Self-Rated Recovery Question
  • Patient-specific Functional Scale
  • Brief Pain Inventory (BPI)
  • Visual Analog Scale (VAS)
  • Patient-Rated Elbow Evaluation (PREE)
  • Patient-Rated Tennis Elbow Evaluation (PRTEE)
  • DASH Outcome Measure
  • Upper Extremity Functional Index

Physical Examination

Incorporate one or more of the following physical examination tools and interpret examination results in the context of all clinical exam findings.

  • Elbow Valgus and Varus Stress Tests
  • Moving Valgus Stress Test of the Elbow
  • Cozen’s Test
  • Mill’s Test
  • Medial Epicondylitis Test (Golfers Elbow)
  • Tinel’s Sign’s at the Elbow (Cubital Tunnel Syndrome)
  • Pronator Teres Syndrome Test
  • Upper Limb Tension Tests (1, 2, 3, & 4)

Treatment

Education

Provide reassurance and patient education on condition and management options and encourage the use of active approaches (lifestyle, physical activity) to help manage symptoms.

Manual Therapy

A massage therapy treatment plan for elbow pain should be implemented based on patient-specific assessment findings and patient tolerance. Structures to keep in mind while assessing and treating patients suffering from elbow pain may include neurovascular structures and investing fascia of:

  • Scalene Muscle Group (anterior scalene, middle scalene, and posterior scalene)
  • Pectoral Region (pectoralis major, pectoralis minor, serratus anterior and subclavius)
  • Rotator Cuff (subscapularis, infraspinatus, teres minor, supraspinatus)
  • The Upper Arm (biceps brachii, brachialis, coracobrachialis, triceps brachii)
  • Anterior Interosseous Membrane
  • Common Extensor Tendon (extensor carpi radialis brevis, extensor digitorum, extensor digiti minimi, extensor carpi ulnaris)
  • Common Flexor Tendon (pronator teres, flexor carpi radialis, palmaris longus, flexor digitorum superficialis, flexor carpi ulnaris)
  • Carpal Bones (trapezium, trapezoid, capitate, hamate, scaphoid, lunate, triquetrum, pisiform)

Self-Management Strategies

Massage therapists not only provide hands-on treatment they can also develop self-management programs to help patients manage symptoms. Simple home-care recommendations such as strengthening exercises for the forearm may be useful for people with elbow pain (Karanasios et al., 2020).

Prognosis

Prognosis is good for the conservative management of elbow pain (Piper et al., 2016). Massage therapists are uniquely suited to incorporate a number of rehabilitation strategies for patients with elbow pain including soft tissue massage, simple home-care recommendations and remedial exercise.


Massage Sloth: Massage for Elbow Pain


Key Takeaways

Contemporary multimodal massage therapists are uniquely suited to incorporate a number of rehabilitation strategies for elbow pain based on patient-specific assessment findings including, but not limited to:

  • Manual Therapy (soft tissue massage, neural mobilization, joint mobilization)
  • Education that is Person-Centered (e.g., biopsychosocial model of health and disease, self-efficacy beliefs, active coping strategies)
  • Stretching & Loading Programs (e.g., concentric, eccentric, isometric exercises)
  • Hydrotherapy (hot & cold)
  • Self-Management Strategies (e.g., engaging in physical activity and exercise, social activities, and healthy sleep habits)

References and Sources

Bordachar, D. (2019). Lateral epicondylalgia: A primary nervous system disorder. Medical hypotheses, 123, 101–109. doi:10.1016/j.mehy.2019.01.009

Coombes, B. K., Bisset, L., & Vicenzino, B. (2015). Management of Lateral Elbow Tendinopathy: One Size Does Not Fit All. The Journal of orthopaedic and sports physical therapy, 45(11), 938–949. doi:10.2519/jospt.2015.5841

Coombes, B. K., Connelly, L., Bisset, L., & Vicenzino, B. (2016). Economic evaluation favours physiotherapy but not corticosteroid injection as a first-line intervention for chronic lateral epicondylalgia: evidence from a randomised clinical trial. British journal of sports medicine, 50(22), 1400–1405. doi:10.1136/bjsports-2015-094729

Docking, S. I., & Cook, J. (2019). How do tendons adapt? Going beyond tissue responses to understand positive adaptation and pathology development: A narrative review. Journal of musculoskeletal & neuronal interactions, 19(3), 300–310.

Gadau, M., Zhang, S. P., Wang, F. C., Liguori, S., Li, W. H., Liu, W. H., Bangrazi, S., Berle, C., Razavy, S., Bian, Z. X., Filomena, P., Hao, Y., Jiang, H. L., Lei, L., Li, T., Zaslawski, C., Liguori, A., Liu, Y. S., Lu, A. P., Tan, Y. S., … Xie, C. L. (2020). A multi-center international study of acupuncture for lateral elbow pain – Results of a randomized controlled trial. European journal of pain (London, England), 24(8), 1458–1470. https://doi.org/10.1002/ejp.1574

Karanasios, S., Korakakis, V., Whiteley, R., Vasilogeorgis, I., Woodbridge, S., & Gioftsos, G. (2020). Exercise interventions in lateral elbow tendinopathy have better outcomes than passive interventions, but the effects are small: a systematic review and meta-analysis of 2123 subjects in 30 trials. British journal of sports medicine, bjsports-2020-102525. Advance online publication. https://doi.org/10.1136/bjsports-2020-102525

Lucado, A. M., Dale, R. B., Vincent, J., & Day, J. M. (2019). Do joint mobilizations assist in the recovery of lateral elbow tendinopathy? A systematic review and meta-analysis. Journal of hand therapy, 32(2), 262–276.e1. doi:10.1016/j.jht.2018.01.010

Magnusson, S. P., & Kjaer, M. (2019). The impact of loading, unloading, ageing and injury on the human tendon. The Journal of physiology, 597(5), 1283–1298. doi:10.1113/JP275450

Piper, S., Shearer, H. M., Côté, P., Wong, J. J., Yu, H., Varatharajan, S., … Taylor-Vaisey, A. L. (2016). The effectiveness of soft-tissue therapy for the management of musculoskeletal disorders and injuries of the upper and lower extremities: A systematic review by the Ontario Protocol for Traffic Injury management (OPTIMa) collaboration. Manual therapy, 21, 18–34. doi:10.1016/j.math.2015.08.011

Yi, R., Bratchenko, W. W., & Tan, V. (2018). Deep Friction Massage Versus Steroid Injection in the Treatment of Lateral Epicondylitis. Hand (New York, N.Y.), 13(1), 56–59. doi:10.1177/1558944717692088

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Evidence-Based Massage Therapy by Richard Lebert is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License, except where otherwise noted.

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