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Bones, Joints, Muscles: Repetitive Strain Injury: Tennis Elbow and Myofascial Trigger Points  Next

Tennis Elbow and Myofascial Trigger Points

by: Jeff Anliker, LMT

Pain 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 Points.

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).


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.

By 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 Elbow", 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 treated, 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.

Trigger 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 wrist/forearm.

Trigger 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

Activities that Increase Pain/Symptoms Associated with Trigger Points

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.

Manual Testing for "Tennis Elbow"

Testing the Supinator Muscle:
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.

NOTE: Supinator 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 to supination.

Associated Trigger Points are also often found in the:
Triceps Brachii
Finger Extensors
Extensor Carpi Radialis Longus
Extensor Carpi Radialis Brevis
Brachioradialis muscle.
A Trigger Point within the Anconeus may also refer pain to the lateral epicondyle)

Other 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 Muscles:

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.

HandGrip Test:
If 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.

Compression Test:
The 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.

Pinpointing the Pain:
Identification 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 shortened position.

Pain Referral and Tennis Elbow

Supinator - Pain at lateral epicondyle with general ache in anterior forearm.
Extensor 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)
Extensor Carpi Radialis Brevis - Pain is referred to the back of the hand and wrist.
Extensor Carpi Ulnaris - Pain is referred to the posterior / ulnar side of the wrist.
Extensor Digitorum - Pain is referred from the lateral epicondyle, down the forearm to the back of the hand and fingers.
Extensor 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.

Activities 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 handle , 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)

Other Contributors / Causes of Tennis Elbow:

Trying to unscrew a jar lid that is stuck, especially with fingertips.
Wringing out wet rags/washcloth
Walking a dog that is pulling hard on the leash
Raking leaves
Falling onto outstretched hand
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

PROBLEM: Trigger 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.


1. Examples 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.

2. Examples 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)
NOTE: Any one of the situations described above can cause trauma and associated trigger points within the involved muscle(s).

Eliminate Tennis Elbow

The 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 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).

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!

Strengthening 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!

Jeff P. Anliker, LMT, is a therapist and inventor of products that are used by professional musicians and athletes an around the world to prevent and treat disorders like carpal tunnel syndrome and repetitive strain injuries.

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(Added: Mon Jan 15 2007 Hits: 1486 Downloads: 0 Rating: 0.00 Votes: 0)   Rate It   Review It


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