Elbow and Myofascial Trigger points
associated with Tennis Elbow is often times the
result of active Myofascial Trigger Points affecting
the Supinator, Extensor Carpi Radialis Longus
and the Extensor Digitorum muscles. Trigger Points,
if treated properly by therapist, will reproduce
the patient's "painful symptoms", exactly like
they (Patients) would "normally" experience the
pain during active use and/or during rest, depending
upon which muscle(s) are afflicted with Trigger
Myofascial Trigger Points
consist of localized tender spots in
a tense band of muscle fibers that when subjected
to direct pressure, refer pain to other areas along
the length of the involved muscle(s).
ELBOW AND MYOFASCIAL TRIGGER POINTS
Treating Trigger-Points by
pressing downward and maintaining the pressure directly
on the active Trigger Point and mimicking the exact
pain experienced by the patient when their symptoms
are at their worst breaks the pain-cycle and eliminates
the patient's symptoms.
reducing the symptoms enough to where the patient
can be active allows
the patient the ability to recover much faster. If
the patient remains sedentary due to pain and dysfunction,
the Trigger Points will establish themselves in the
muscle/tendon, making them more difficult to eliminate.
Although many physicians
have diagnosed and "treated" patients suffering from "Tennis
prescribing anti-inflammatory medications, complete
rest, and ice-therapy. More often then not, their
diagnosis was/is incorrect because there is no visible
or palpable inflammation, no discoloration of the
skin, and the pain continues to radiate even when
the patient is at rest.
If Trigger Points are not
the tender, restrictive, and very taught bands
of muscle will become strained at the muscle/tendon
(Musculotendinous Junction) or at the tendon/bone
(Tenoperiosteal Junction). The tensile strain imposed
upon the muscles can cause micro-tears within the
muscle/tendon or tendon/bone, resulting in irritation,
inflammation, and fibrotic tissue changes within
the muscle/tendon. Finally - A TRUE CASE of "Tennis
Elbow" we can treat with all of the medications,
and possibly even surgery!
Address Tennis Elbow pain
as soon as you can by
making an appointment with a qualified / Professional
therapist that knows how to eliminate Trigger Points.
And, if you ever want to eliminate the possibility
of strain of any muscle or tendon - You must strengthen
that muscle and tendon so that it is stronger than
the amount of stress or active resistance that it
will be subjected to. If I can only extend and supinate
my wrist and fingers against 20-lbs. of resistance,
I had better not plan on doing anything that requires
me to resist 50-lbs. unless of course I want to be
severely injured in the process.
Points = Tennis Elbow
The symptoms associated
with "Tennis Elbow" are
often directed to the inflammation and damage of
the finger and wrist extensor muscles - ONLY. Although
these muscles can certainly be involved in cases
of Tennis Elbow, the injury is more often caused
by active Myofascial Trigger Points in the Supinator
muscle due to the strain of this muscle while engaged
in resisted pronation or forceful supination of the
Points and Pain Sequence
The muscles surrounding
the elbow joint that
cause lateral epicondyle pain are likely to develop
Trigger Points in the following sequence.
- Extensor Carpi Radialis Longus
- Extensor Digitorum
- Triceps Brachii
- Biceps and Brachialis combined
that Increase Pain/Symptoms Associated with Trigger
The type of activities usually
responsible for the activation of these Trigger Points involves
incorrect use or overuse of the tennis "backhand", "flipping" a
briefcase onto the top of a desk with the arm in
a straight, unflexed position, repetitive finger
flexion/extension and repetitive/static gripping
with the hands.
Testing for "Tennis Elbow"
Testing the Supinator
If the Supinator muscle is the source of the symptoms experienced
by the patient, examination of the lateral epicondyle by "tapping" on it will
exhibit tenderness and referred pain.
Performing resisted supination will also exhibit pain and tenderness, thus revealing
Trigger points affecting the Supinator muscle.
Individuals with trigger points in the Supinator muscle may complain of pain
in both the lateral epicondyle and the dorsal surface of the web of the thumb,
or just one of these areas may exhibit symptoms. Almost every patient with
pain directed over the lateral epicondyle has a Trigger Point in the Supinator
muscle, and is the MOST COMON CAUSE of "Tennis Elbow" pain.
Muscle: The Supinator muscle acts to supinate the hand and secondarily assist
in flexion at the elbow. Supinator activity predominates over biceps activity
during un-resisted supination of the hand, and is responsible for "holding/maintaining" the
hand in a supinated position. Although the biceps is usually thought of as
the main supinator muscle of the wrist and forearm, the biceps is only activated
if the elbow is flexed (Even slightly), and when strength is needed to overcome
resistance to the supination of the hand/forearm. When the arm is straight,
with the elbow in an extended position, the biceps does nothing in regards
Trigger Points are also often found in the:
- Triceps Brachii
- Finger Extensors
- Extensor Carpi
- Extensor Carpi
- A Trigger Point
within the Anconeus may also refer pain to the lateral epicondyle)
muscles associated with the Supinators Myotatic Unit that may be
involved, but do not refer pain to the Lateral Epicondyle:
- Biceps Brachii
- Palmaris Longus
Testing the Extensor
If the Tennis Elbow symptoms are directly related to
the Extensor muscle group ,
the patient will first experience pain in the lateral epicondyle, and later,
experience the pain in a broader pattern as it radiates and travels downward
into the forearm, wrist, hand and fingers.
the Extensor muscle group is the cause of lateral epicondyle pain,
it will be confirmed upon examination utilizing the Handgrip Test,
which requires the patient to squeeze an object with their hand cocked
in radial deviation at the wrist (Normal thumb-up hand-shake position),
and then un-cocked in ulnar deviation. If the HandGrip Test is positive,
the patient will experience considerable pain and weak grip-strength
in the "un-cocked" ulnar-deviated position much more than the "cocked" radial-deviated
position. As the Therapist moves the patient's hand further and further
into ulnar deviation during the HandGrip Test, it becomes even more
evident that the patient experiences a continual reduction of grip-strength
and increased pain referral patterns.
origin of the pain, exhibited by the Myofascial Trigger Points in
the Extensor muscle group,
is confirmed with the Compression Test. The Compression Test requires
the Therapist to pinch/compress the entire Extensor muscle group
just below the patient's Lateral Epicondyle, and held firm while
the patient again performs the Handgrip Test. The pinching/compressing
of the Extensor muscles will eliminate most of the pain that was
previously experienced during the Handgrip Test. Once the muscles
are no longer compressed/pinched by the Therapist, and the patient
performs the Handgrip Test again, the pain that was initially experienced
by the patient will again be present.
of the involved muscle(s) can also be confirmed by
causing / creating referred pain within the suspected muscle when
it is passively stretched, and/or when it is actively loaded in the
Pain Referral and Tennis
- Supinator -
Pain at lateral epicondyle with general ache in anterior forearm.
Carpi Radialis Longus - Pain and tenderness is
referred from the lateral epicondyle down the arm to the posterior
hand, and anatomical snuff box (Base of thumb)
Carpi Radialis Brevis - Pain is referred to the
back of the hand and wrist.
Carpi Ulnaris - Pain is referred to the posterior
/ ulnar side of the wrist.
Digitorum - Pain is referred from the lateral
epicondyle, down the forearm to the back of the hand and fingers.
Indicis - Pain is referred to the back of the
hand and wrist.
- Brachioradialis -
Pain is referred to the lateral epicondyle and down the length of
the arm to the posterior aspect of the web of the thumb.
that Increase / Cause Symptoms Associated with Tennis Elbow:
Strain can occur at any time when resisting unexpected
pronation / flexion or performing forceful supination / extension) of the wrist/forearm. Any
type of strenuous force, repetitive motions and/or sustained supination/extension
of the hand/wrist, especially when the elbow is straight, can cause injury to
the Supinator and Extensor muscles, and refer pain to the lateral epicondyle.
Carrying a briefcase with the elbow straight (Fully
extended) forces the Supinator to stabilize rotation of the wrist/forearm. This
scenario presents even greater chance of injury if the briefcase tends to bump
the individuals leg while walking and causes the briefcase to rotate, which has
to be counteracted by the individual by resisting the pronation of the wrist/forearm
with sudden contraction of the Supinator muscle. Also, heaving a briefcase up
onto a desk with one arm, elbow fully locked in the straight position, forcing
the weight of the briefcase to be directed entirely to the finger and wrist extensors,
thus causing strain to the associated tendons and their origin / insertion points.
Repetitive Flexion while typing,
causing the flexor muscles to become stronger and tighter, thus putting a tensile
strain on the weaker extensor muscles from the constant "pulling" action of
the more restrictive flexor group.
Playing tennis with a racket that has too large of a
which requires much more force to hold it steady, especially if the ball is hit
off-center with the elbow fully extended and wrist in ulnar deviation, causing
the racket to jar forward or rotate forcefully. (Full extension causes direct
load to the Supinator muscle with no assistance from the biceps. If the elbow
is even slightly flexed, the biceps will absorb much of the load and greatly
reduce the chance of strain and injury of the Supinator muscle)
/ Causes of Tennis Elbow:
- Trying to unscrew
a jar lid that is stuck, especially with fingertips.
- Wringing out wet
- Walking a dog
that is pulling hard on the leash
- Raking leaves
- Falling onto outstretched
- Digging with hand-shovel
- And. many other
activities causing excess, continuous or sudden strain to the underdeveloped
Supinator and Extensor muscles.
Trauma, Repeated Stress and
Muscle Overload = Tennis Elbow
Points, Irritation, inflammation and damage of the supinator / extensor tendons
at the tenoperiosteal junction, at the point of origin where the tendons attach
to the Lateral Epicondyle of the humerus. (Upper Arm bone)
ANSWER: Develop adequate strength
to withstand trauma and repetitive use by building up power and muscle endurance.
Build up more endurance, strength to withstand stress to extensors.
of Individual that has enough finger, wrist and elbow extensor strength
and endurance to perform the following three (3) activities on a daily
basis without injury.
||a. Repetition: 10,000
finger/wrist extension repetitions several days in a row (Typing on computers.)
b. Trauma: 60 lbs. Of instant pressure applied once (1x).
c. Resistive Power: 40 lbs. of pressure applied ten times (10x) a day.
of same Individual performing the exact same tasks as listed above, but
now in a situation that has caused injury. The following situations caused
injury because the extensor muscles were not used to, or prepared for
the increased stress placed upon them.
||a. Repetition: Performing
20,000 (instead of 10k.) repetitions several days in a row. Endurance
problem exists. (Typing on computers.)
b. Trauma: 100lbs. (Instead of 60lbs.) of sudden/instant pressure applied
once (1x) to the supinator / extensor muscles, thus stressing supinator/extensor
tendon insertion points on lateral epicondyle. Power/Strength Problem exists.
(Catch a falling weight / dumbbell)
c. Resistive Power: 40lbs. of pressure applied twenty times (20x) per day.
Power/ Endurance problem exists. (Tennis backhand trying to return very
hard serve again and again)
Any one of the situations described above can cause trauma and associated
trigger points within the involved muscle(s).
Eliminate Tennis Elbow
Supinator and Extensor muscles are
easily injured due to their lack of strength and endurance,
and then being subjected to overuse and/or sudden strain while in a position
that causes them be at a mechanical disadvantage when utilized.
Myofascial Trigger Points consist of localized tender
a tense band of muscle fibers that when subjected to direct pressure, refer
pain to other areas along the length of the involved muscle(s).
Strengthening the Supinator and Extensor muscles so
they are prepared for tasks that require direct resistance, and learning to position
the hands/arms correctly during those tasks can greatly reduce the chance of
strain and serious injury to these muscles.
Prevention is the Key!
the Supinator and Extensor muscles, and stretching the pronator and flexor muscles will
prevent the injury from occurring and/or rehabilitate an existing injury. Strength,
power and endurance are the keys to a healthy, pain-free elbow!