Ending Epicondylitis
by Tim Agnew

If you have been a massage therapist for any period of time, you’ve probably seen clients suffering from epicondylitis, or have battled the condition yourself. Like most overuse injuries, it can become a chronic, painful ordeal, especially for the busy therapist with back-to-back appointments. While this condition is common in athletics—it accounts for as much as 50 percent of all athletic injuries—the epicondylitis epidemic in the United States does not reside in athletes alone.1 The Bureau of Labor Statistics reports approximately 68,000 cases of elbow-related tendinitis cases per year in private industry, but there are plenty of others suffering from this condition.2 Like any chronic condition, treating epicondylitis can be tricky. With the right tools and a specific approach, non-surgical treatment can be successful, both for you and your client.

The Condition

Most therapists know epicondylitis as “tennis elbow” or “golfer’s elbow;” the former affecting the lateral epicondyle, the latter the medial epicondyle. The client might present with burning, numbness or extreme tenderness over the epicondyle. At its worst, the client will report he or she can no longer hold a mug of coffee.

From its name, epicondylitis is a tendinitis to the tendons of the forearms; “itis” means inflammation. Yet in my experience most cases involve something else called tendinosis. So what is the difference and why is it so important to the therapist?

Tendinitis is an inflammatory response within the collagen triggered by an overuse activity. Swelling of tendons and local tenderness are common. A good example is tendinitis of the rotator cuff tendons of the shoulder; once inflamed, these tendons impinge under the acromion. The inflammation can be the beginning of a more severe situation, tendinosis. Tendinosis is a pathology of chronic degeneration to the tendon matrix; it is an accumulation over time of microscopic injuries that do not heal properly. The important differences between the two are the lack of tendon inflammation in someone with tendinosis, and misalignment of tendon fibers.

In a study performed during surgery of more than 600 cases of lateral elbow tendinitis, the extensor carpi radialis brevis tendon contained disrupted collagen fibers and no inflammatory cells.3 Therefore, a solid treatment plan should assume tendinosis, or failed healing to damaged matrix of the collagen, and not tendinitis, especially if the client admits to months of pain.

Tendinopathies become chronic because the athlete or worker continues to compete in sports or activity with the condition. This is common in many injuries. The pain becomes part of the client’s life, and even normal activities can make it worse. Like many injuries in soft tissue, epicondylitis sneaks up on you. It starts with a burning or tenderness after intense activity, then snowballs into a worse condition. It is important for you and the client to recognize these early warning signs, so you can refer him or her out to get a proper diagnosis. These early signs usually mean a worse scenario is waiting to happen. While it is often difficult to work with the client in the early stage, treatment can still be successful if the proper steps are implemented.

Traditional Treatments

Some of the traditional, non-surgical treatments for epicondylitis include injected corticosteroids, bracing and physical therapy. The success rate for these treatments can be good, for a short time. The problem with many of these treatments is the “short term” mentality. The client relies on the provider to solve his problem, so when the pain returns he must receive another injection, more physical therapy, or worse, pills.

Since tendinopathy issues often involve excessive injury to the tendons, treatment philosophy should include long term, client-involved care. Unfortunately, there are no 20-minute treatments that will resolve tendinopathies. With a specific, isolated approach, however, recovery can occur.

A Different Approach

While massage therapy can be helpful at easing the pain in the forearm–especially when it is applied to specific extensor and flexor muscles–engaging these muscles using flexibility and resistance is also necessary. Treating epicondylitis must be specific and empowering. The client must be motivated to heal or long-term results will not occur. When dealing with a chronic, painful condition, it is not difficult to get client compliance; most are desperate to find a solution. The athlete wants to return to the courts, the mother wants to hold her baby.
The therapy approach for epicondylitis has many specific goals. The first consideration is muscle flexibility. One of the goals in restoring range of motion (ROM) is to improve natural movement, preventing compensation from the rest of the body. Flexibility also increases blood flow and improves muscle tendon alignment, and in the process dislodges scar tissue along both epicondyles. Remember, in tendinosis we are dealing with tendon damage that needs a chance to heal, so stretching can help move the process along.

Another consideration is why a client develops epicondylitis in the first place. In general terms, tendinopathies evolve due to an imbalance in the muscles of the forearms. The flexors are weaker than the extensors, or vice versa. A weak muscle cannot handle vector forces placed upon it in overuse movements. The serious tennis player might rebuke a therapist’s suggestion that he is “weak” in his extenders along the lateral epicondyle. “I play tennis six days a week. How could I be weak?” he might say. But weaknesses exist because of limited specific strengthening of these muscles. This is one of the reasons many professional tennis players now strength train all-year long.
After both of these goals have been achieved, the client must be educated on how to maintain the condition. This involves simple weekly exercises. It must be made clear that there is no solution without client contribution. For example, eight weeks of maintenance exercises might improve the condition, but only through continued dedication to a lifetime program will the solution materialize.

A typical physical therapy program for epicondylitis might involve many forearm dumbbell exercises such as wrist flexion and extension. While these movements might help heal a tendinopathy, it is necessary to be more specific. Some of the things I presume when assessing any dysfunction is that there are compromised movements relating to ignored muscle groups. For example, with epicondylitis we understand there is an imbalance between the flexors and extensors, but elbow flexion and extension are common movements in normal activities. While this does not mean we should ignore these movements in therapy, it does mean that this muscular group has some stability from movement. A less uncommon set of movements are radial and ulnar rotation, extension and flexion.

Clients need learn about their conditions, and how they can maintain them. It is not up to you as a therapist to solve their dysfunction; you are merely the guide. The client has to take a proactive stance that lasts a lifetime and you must empower them to do so. Chronic conditions such as epicondylitis require constant maintenance. But this does not mean eight hours per day of grueling exercises. Just 20 to 30 minutes every other day is all that is required once the injury has healed.

References
1. Kannus P. “Tendons-a source of major concern in competitive and recreational athletes.” [Editorial]. Scand J. Med Sci Sport. 1997;7:53-54.
2. Bureau of Labor Statistics, 2005.
3. Kraushaar BS, Nirschi RP. “Tendinosis of the elbow (Tennis Elbow). Clinical features and findings of histological, immunohistochemical, and electron microscopy studies.” J Bone Joint Surg. 1999; 81-A:269-278.


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