- Home
- Physical Therapy/Physiotherapy
- Massage Therapy
- Health Care in Exercise and Sport
- Sports Massage for Injury Care
Sports Massage for Injury Care
224 Pages
No two injuries are the same. Whether an injury is acute or chronic, you need to understand and treat the underlying cause so you don’t leave your athletes susceptible to re-injury. Sports Massage for Injury Care emphasizes the importance of accurate assessment and evaluation, and it focuses on 20 of the most common neuromuscular injuries seen in athletes. For each featured injury, there are assessment recommendations, treatment options and injury-specific protocols, and self-care options for when the athlete is not on the treatment table.
You will learn the evidence behind the techniques that are most effective, based on clinical research. Each treatment protocol is presented with vivid full-color photos and step-by-step instructions. Detailed anatomical illustrations show you the muscles, joints, and soft tissues involved. Practitioner examples and case studies give you a glimpse into how other practicing professionals use the techniques to help their clients heal quicker and more fully.
Clinical sports massage therapy is often the missing component in injury-rehabilitation programs. With Sports Massage for Injury Care, you have the ultimate practical resource for relieving pain and getting your clients and patients back to their athletic endeavors and daily activities as quickly as possible.
Chapter 1. Concepts and Principles
The Process of Clinical Reasoning
Pain Science
Chapter 2. Reviewing Soft Tissue Types
Connective Tissue
Fascia
Ligaments
Tendons
Muscles
Nerves
Chapter 3. Principles of Assessment
HOPS Method
Assessing Active, Passive, and Resisted Motion
Additional Tests
Perpetuating Factors
Part II. A Closer Look at Injury and Repair
Chapter 4. Soft Tissue Injury
Acute Injuries
Chronic Injuries
Soft Tissue Injury Repair Process
Chapter 5. Soft Tissue Techniques
Compressive Effleurage
Compressive Petrissage
Broad Cross-Fiber Stroke
Longitudinal Stripping
Pin-and-Stretch Techniques
Isolytic Contractions
Deep Transverse Friction
Facilitated Stretching
Part III. Common Neuromuscular Injuries
Chapter 6. Treatment of Lower-Extremity Soft Tissue Injuries
Achilles Tendinopathy
Lateral Ankle Sprain
Groin Strain
Hamstring Tendinopathy
Iliotibial Band Syndrome (ITBS)
Medial Collateral Ligament (MCL) Sprain
Patellar Tendinopathy
Peroneal (Fibularis) Tendinopathy
Plantar Fasciitis/Fasciopathy
Shin Splints
Chapter 7. Treatment of Upper-Extremity Soft Tissue Injuries
Rotator Cuff
Tennis Elbow
Golfer’s Elbow
Bicipital Tendinopathy
Chapter 8. Sports Massage for Nerve Entrapment Syndromes
Quadrilateral Space Syndrome (QSS)
Thoracic Outlet Syndrome (TOS)
Carpal Tunnel Syndrome (CTS)
Cubital Tunnel Syndrome
Tarsal Tunnel Syndrome
Piriformis Syndrome (PS)
Robert E. McAtee, BA, LMT, BCTMB, CSCS, has maintained a full-time massage therapy practice for over 38 years, specializing in sports massage and soft tissue therapy, with significant clinical experience in treating people with injuries and chronic pain. Since 1988, he has owned Pro-Active Massage Therapy, an international private practice in Colorado Springs, Colorado.
McAtee is designated an Approved Provider by the National Certification Board for Therapeutic Massage and Bodywork (NCBTMB). He is a sought-after presenter—throughout the United States and worldwide—on the topics of facilitated stretching, sports massage, and soft tissue injury care.
McAtee received his massage training at the Institute for Psycho-Structural Balancing (IPSB) in Los Angeles and San Diego and through the Sports Massage Training Institute (SMTI) in Costa Mesa, California. He holds a bachelor’s degree in psychology from California State University, is board certified in therapeutic massage and bodywork, and is a certified strength and conditioning specialist. He has been an active member of the American Massage Therapy Association since 1988.
He is also the coauthor of the best-selling book Facilitated Stretching, Fourth Edition, used by health and fitness professionals worldwide as their go-to resource for PNF stretching and strengthening techniques.
“Having read and used Bob's previous book for professional use, I'm excited for his expertise and knowledge of the sport massage industry shown in Sports Massage for Injury Care. Massage therapists will benefit tremendously from this step-by-step guide to assessment and treatment of sport injuries. In addition, all manual therapists will be able to use this great resource in their clinical practice.”
—Joanne Baker, Registered Massage Therapist and Instructor
“With my 44 years of experience in massage therapy and sports, I can say that Bob McAtee's Sports Massage for Injury Care has covered ALL the critical bases! This should be required reading in any massage therapy, athletic training, physical therapy, or chiropractic curriculum. Bob has done a terrific job of demonstrating that therapeutic intervention MUST include hands-on soft tissue therapy—period!”
—Benny Vaughn, LMT, ATC, CSCS, MTI, Master Therapist and Career Success Coach
“Bob McAtee has written the must-read book for any practitioner interested in sports massage. Read Sports Massage for Injury Care and learn from one of the best clinicians and educators I know.”
—Wade Alberts, LMT, Two-Time Olympic Medical Staff Member
“Bob McAtee is one of the most trusted practitioners and educators in the massage therapy profession. His latest book, Sports Massage for Injury Care, should be considered a must-have for any health care provider looking to advance their knowledge and skill set in the domain of sports massage.”
—Keenan Robinson, Sports Medicine and Science Director for USA Swimming
Cryotherapy for acute injuries
Athletes and sports practitioners have used ice, or cryotherapy, to control the pain and inflammation of acute and chronic injuries for generations.
Athletes and sports practitioners have used ice, or cryotherapy, to control the pain and inflammation of acute and chronic injuries for generations. There is broad agreement among practitioners that inflammation is a necessary component of the healing process, but excessive or prolonged inflammation may delay or disrupt the completion of the healing process. Cryotherapy has traditionally been used to limit but not eliminate inflammation, as well as to control swelling and reduce pain.
Kenneth Knight, PhD, ATC, published Cryotherapy in Sport Injury Management in 1995, and it quickly became the go-to cryotherapy resource for practitioners. He has since written several textbooks for athletic trainers, including one with David O. Draper, Therapeutic Modalities: The Art and Science, Second Edition, published in 2013. They include an extensive and well-referenced discussion supporting the proper use of cryotherapy in the treatment of acute, subacute, and chronic injuries.
In recent years, a significant anticryotherapy movement has emerged, arguing that enough research now exists to show that cryotherapy applications delay healing of acute injuries. Gabe Mirkin, MD, is one of the experts who has published commentary against the use of ice. Mirkin takes credit for coining the acronym RICE when he and coauthor Marshall Hoffman published The Sports Medicine Book (1978). In 2015, Mirkin walked back his thinking on RICE, especially the use of ice to control inflammation.
Dr. Mirkin refers to a 2004 review of 22 studies that found almost no evidence that ice and compression promoted faster healing. The study authors concluded,
There was little evidence to suggest that the addition of ice to compression had any significant effect, but this was restricted to treatment of hospital inpatients. Few studies assessed the effectiveness of ice on closed soft tissue injury, and there was no evidence of an optimal mode or duration of treatment. (Bleakley, McDonough, and MacAuley 2004, p. 220)
It's important to note that this review did not find evidence that ice and compression delayed healing.
Two other popular proponents of the no-ice approach for acute injury are Gary Reinl, the author of Iced! The Illusionary Treatment Option (2014), and Josh Stone, ATC, CSCS, who has written extensively on his blog on the detrimental effects of cryotherapy for acute injuries (stoneathleticmedicine.com). Both of these authors provide ample research to support their conclusions.
The anti-ice proponents argue that, although ice may provide some pain relief, it delays healing by interrupting the inflammatory process, by interfering with the removal of edema from the injured area, and by preventing or slowing the release of the hormone known as insulin-like growth factor (IGF-1). IGF-1 stimulates cell growth and proliferation and inhibits cell death.
In a 2011 animal-based experiment, the effects of cryotherapy on healing after a skeletal muscle crush injury were studied (Takagi et al.). Immediately following the lab-induced injury, the experimental rats were randomly divided into no-ice and icing groups. In the latter, crushed-ice packs were applied for 20 minutes. The authors then microscopically and physiologically analyzed the healing progression of the injured muscles at 12 hours and then every day for the first 7 days and at 14 and 28 days after the injury. The results of the study showed that “icing applied soon after the injury not only considerably retarded muscle regeneration but also induced impairment of muscle regeneration along with excessive collagen deposition” (Takagi et al. 2011, p. 388). The takeaway from these results is that cryotherapy applied immediately postinjury has both short-term and long-term negative effects on muscle healing. It appears that the temporary pain relief afforded by using ice for 20 minutes creates detrimental effects on the muscle-healing process and may produce weaker and more fibrotic muscle tissue.
A separate study also indicates that icing may produce fibrosis during the healing process (Shibaguchi et al. 2016). The researchers applied ice for 20 minutes to injured rats, then applied heat stress (107°F for 30 min) on the experimental group every other day for the next 14 days. They found that the recovery of muscle mass, protein content, and muscle fiber size toward the levels of the uninjured control group was greater in the heat-stress group and that fibrosis increased in the icing-only group. These findings indicate that using heat on acute injuries, previously anathema, may instead be a viable intervention to promote complete healing of injured skeletal muscles.
As the ice versus no-ice debate continues, practitioners are using several alternative interventions to promote more efficient recovery from acute injury. These may include treatments based on traditional Chinese medicine, or variations on the RICE protocol.
Traditional Chinese Medicine Traditional Chinese medicine (TCM) has always eschewed the use of ice for treating acute injuries. According to Bisio (2004), TCM sports medicine practitioners believe that cold and damp invades the injured area, congesting and congealing the blood and qi (also written as chi and meaning vital energy). This stagnation leads to a cascade of effects, including chronic swelling that is hard to disperse and “an arthritic type of pain that often increases with weather changes and is difficult to treat” (Bisio 2004, p. 23). TCM offers several alternative interventions to treat the swelling and inflammation of acute injuries. These include acupuncture, herbal poultices, massage with special liniments, cupping and bleeding, and oral herbal remedies.
POLICE Bleakley and colleagues (2012) have proposed POLICE(protection, optimal loading, ice, compression, and elevation). According to this editorial,
POLICE . . . is not simply a formula but a reminder to clinicians to think differently and seek out new and innovative strategies for safe and effective loading in acute soft tissue injury management. Optimal loading is an umbrella term for any mechanotherapy intervention and includes a wide range of manual techniques currently available; indeed, the term may include manual techniques such as massage refined to maximise the mechano-effect… POLICE is not just an acronym to guide management but a stimulus to a new field of research. It is important that this research includes more rigorous examination of the role of ICE in acute injury management. Currently, cold-induced analgesia and the assurance and support provided by compression and elevation are enough to retain ICE within the acronym. (2012, p. 220)
MEAT MEAT (movement, exercise, analgesia, treatment) has emerged as another alternative to RICE for treating acute soft tissue injuries, especially injuries to tendons and ligaments. The rationale for using MEAT is that early movement and appropriate exercise is better for recovery than immobilization. Buckwalter (1995) discussed the importance of controlled early resumption of activities to promote restoration of ligament and tendon function.
A systematic review of 21 studies was done in 2002 to compare the results of immobilization versus functional treatment for acute lateral ankle sprains. The reviewers concluded that
Functional treatment appears to be the favourable strategy for treating acute ankle sprains when compared with immobilisation. However, these results should be interpreted with caution, as most of the differences are not significant after exclusion of the low-quality trials. Many trials were poorly reported and there was variety amongst the functional treatments evaluated. (Kerkhoffs et al. 2002, p. 2)
As physicians, sports medicine practitioners, and researchers continue to explore these issues, it's important to remember that while each of these approaches has pros and cons, the quality of the research comparing these interventions leaves a lot to be desired. At this point in the debate, however, it appears safe to assume the cryotherapy portion of RICE is ill-advised, and movement is preferred over immobilization. The challenge for sports massage therapists is to understand, and to help their athletes understand, the rationale for not using ice, especially those athletes with a long history of using ice as their recovery modality of choice.
Understanding the science of pain
An explosion of research on pain in recent years has led to new insights into, as well as great confusion about, the origins of pain, the connections between injury and pain, and the psychological and social contributions to the perception of pain.
An explosion of research on pain in recent years has led to new insights into, as well as great confusion about, the origins of pain, the connections between injury and pain, and the psychological and social contributions to the perception of pain. This broadened knowledge of the complexity of pain has also affected the way manual therapy practitioners approach their work with clients.
By contrast, as the understanding of the mechanisms of pain perception and pain generation has progressed, many researchers and practitioners have reframed the discussion of pain in relation to injury by emphasizing that pain is a complex experience, involving many parts of the brain, and that pain perception is influenced by psychosocial factors that include previous pain experiences, thoughts and feelings about previous pain experiences, emotional states, and even personal relationships. These elements of the pain experience have been recognized for years but have been downplayed in favor of a pathomechanical model of pain that described the stimulation of pain receptors in the tissue when an injury or insult occurred there. These receptors would then stimulate the pain region of the brain, and pain would be felt. It now appears that pain receptors do not exist, but nociceptive receptors do and are stimulated by a variety of noxious stimuli, including pressure, temperature, and inflammatory markers. These receptors send signals to the brain via the spinal cord, and the brain evaluates the signal and determines whether the input is pain or not, and then outputs either the sensation of pain or something else, such as an increase in pressure or a feeling of additional warmth. What this means in practical terms for practitioners is that pain intensity does not necessarily correlate with tissue damage. Minor injuries can feel extremely painful, and severe injuries may occur with very little pain. This response is modulated by the brain and is dependent on all the biopsychosocial factors influencing the brain's final output.
In chronic pain conditions, a neural pathway can become sensitized by repeated nociceptive stimulation so that even minor noxious input can trigger output from the brain that causes the patient to feel pain. On the other hand, this does not mean that pain intensity never correlates directly with the amount of tissue damage, and it's critical for practitioners and patients to stay mindful of this fact.
Growing evidence indicates that incorporating pain neuroscience education (PNE) with manual treatment is efficacious for reducing chronic pain. The intent of PNE is to help shift the client's focus away from “my tissues are painful, so they must be injured” to realizing that the brain's perception and interpretation of stimuli emanating from the tissues may not always accurately reflect the degree of tissue damage. Encouraging a client to shift their focus away from the idea that their pain is caused by specific tissue damage has been shown to reduce chronic pain and, more importantly, to reduce pain catastrophization (magnifying the pain and feeling helpless in the presence of pain).
As practitioners and patients read and hear more about the new pain science, they may make the incorrect assumption that the oversimplified phrase “pain is in the brain” means that pain is all in your head. It's incumbent on the professionals to reassure patients that they're not making it all up (as has been the unfortunate experience of many patients). As Whitney Lowe, massage educator and author, has written,
I think one of the biggest obstacles and challenges for those who are carrying the torch of the emerging pain science specialty is to understand how to introduce these ideas to those for whom this view is new. Too often I have seen and heard pain science enthusiasts speak to others with condescension and arrogance. As a teacher I clearly recognize how that produces an immediate degree of defensiveness in a student and that is a significant obstacle to learning. (Lowe 2017, p. 1)
Because knowledge about pain perception continues to emerge and evolve, the other clear message for practitioners and patients is that our prior knowledge and experience about pain and treating patients in pain is not suddenly obsolete or ineffective. “It isn't necessary to throw out all of the valuable learning and clinical experience we have already built upon. But maybe we look at these things through a different set of glasses” (Lowe 2017, p. 1). It is incumbent on sports massage practitioners to discuss with clients the current research about pain and how those research findings will affect the treatment strategies proposed in their particular case.
What is tennis elbow?
Tennis elbow (lateral epicondylitis) is the most common overuse injury of the elbow, resulting from repetitive strain to the common extensor tendons of the wrist.
Tennis elbow (lateral epicondylitis) is the most common overuse injury of the elbow, resulting from repetitive strain to the common extensor tendons of the wrist. Although this condition is named for a sport in which it's common, it can also occur in other activities that involve repetitive stress on the wrist extensors.
Signs and Symptoms
Lateral epicondylitis (or epicondylosis if no inflammation is present) is characterized by a deep ache at the lateral epicondyle that is made worse by activity. Other symptoms may include pain at the lateral elbow, mild to moderate swelling, and limitation of wrist extension or flexion. The athlete may also experience sudden twinges of extreme pain. In well-advanced cases, sharp pain is often reported when gripping a racket or even shaking hands.
Typical History
Tennis elbow, like most overuse conditions, develops gradually over several months. It may flare up suddenly as a result of increased intensity of activity, such as competing in a tennis tournament. If the injury is not the result of a racket sport, look for repetitive motion in the client's daily activities.
Relevant Anatomy
In most cases, the primary injury is tendinopathy of the extensor carpi radialis brevis (ECRB) tendon, just distal to its attachment on the lateral epicondyle. The rest of the wrist and finger extensors may be affected by the presence of tennis elbow, either by becoming hypertonic or by becoming inhibited because of pain. See figure 7.12 for illustrations indicating the wrist and finger extensors.
Figure 7.12 Wrist and finger extensors.
Extensor Carpi Radialis Brevis
The extensor carpi radialis brevis (ECRB) originates from the common extensor tendon at the lateral epicondyle of the humerus and inserts into the dorsoradial aspect of the base of the third metacarpal bone. Actions include extension of the wrist (with the ECR longus and ulnaris) and assisting radial deviation (abduction).
Extensor Carpi Radialis Longus
The extensor carpi radialis longus (ECRL)originates on the distal third of the lateral supracondylar ridge of the humerus, lying between the origin of the brachioradialis and the lateral epicondyle and inserts into the dorsoradial aspect of the base of the second metacarpal bone. Actions include extending the wrist (along with the ECR brevis and ulnaris) and assisting radial deviation (along with the flexor carpi radialis).
Supinator
The supinator originates from the posterior ulna, the lateral epicondyle, ligaments of the elbow and radioulnar joint, and the anterior capsule of the humeroulnar joint and inserts into the anterolateral aspect of the radius, just distal to the insertion of the biceps brachii. Actions include primary supinator of the hand and forearm; with the elbow flexed, the biceps brachii assists supination and assists elbow flexion when the hand is in neutral.
The radial nerve passes through the supinator muscle, and radial nerve entrapment may create symptoms similar to tennis elbow. Trigger points in the supinator may create referred pain that mimics tennis elbow and can be deactivated as part of the overall treatment for tennis elbow. Fun fact: Because supination is a stronger action than pronation, bolts and screws are designed to tighten by supination of the right forearm (righty-tighty, lefty-loosey).
Anconeus
The anconeus originates from the posterior aspect of the lateral epicondyle of the humerus and inserts into the lateral aspect of the olecranon process and the proximal posterior ulna. Actions include assisting triceps in extension of the elbow and assisting stabilization of the elbow joint during supination and pronation. The anconeus is thought to be secondarily involved in chronic cases of tennis elbow when additional stress placed on it results in compensation or inhibition of the extensor carpi radialis brevis.
Brachioradialis
The brachioradialis originates from the upper two-thirds of the supracondylar ridge of the humerus and inserts into the lateral radius, just proximal to the styloid process. Actions include flexion at the elbow, especially when the hand is in the neutral position; it may assist resisted pronation and supination. The brachioradialis may be secondarily involved with tennis elbow because of its proximity to the extensor carpi radialis longus.
Assessment
Observation
In severe cases, visible swelling over the lateral epicondyle may be present.
ROM Assessment
Active motion at the wrist consists of flexion, extension, abduction (radial deviation), and adduction (ulnar deviation). Depending on the severity of the injury, these motions may or may not cause pain. Passive motion is generally pain free except for wrist flexion, which may stretch painful tissues on the extensor side of the forearm, especially with the elbow extended.
Resisted extension of the wrist is painful. Resisted radial deviation may also be painful.
Manual Resistive Tests
The athlete, sitting or standing, places her wrist in neutral, forearm pronated. The examiner grasps the lateral elbow with one hand, and the other hand provides resistance as the athlete attempts to extend the wrist (see figure 7.13). This isometric contraction should begin slowly and build to a strong engagement of the target muscles. With the elbow flexed, the test will engage the ECR brevis more fully; with the elbow extended, the test will focus more on the ECR longus. Pain or weakness is a positive finding. Resisted extension of the middle finger (also known as Maudsley's test) is commonly positive for pain or weakness in tennis elbow (Fairbank and Corlett 2002) (see figure 7.14). If no pain occurs, the examination widens to include the other muscles that might cause lateral epicondyle pain, such as the supinator, brachioradialis, and anconeus.
Figure 7.13 Resisted wrist extension test: with (a) elbow flexed and (b) elbow straight.
Figure 7.14 Middle-finger extension test.
Cryotherapy for acute injuries
Athletes and sports practitioners have used ice, or cryotherapy, to control the pain and inflammation of acute and chronic injuries for generations.
Athletes and sports practitioners have used ice, or cryotherapy, to control the pain and inflammation of acute and chronic injuries for generations. There is broad agreement among practitioners that inflammation is a necessary component of the healing process, but excessive or prolonged inflammation may delay or disrupt the completion of the healing process. Cryotherapy has traditionally been used to limit but not eliminate inflammation, as well as to control swelling and reduce pain.
Kenneth Knight, PhD, ATC, published Cryotherapy in Sport Injury Management in 1995, and it quickly became the go-to cryotherapy resource for practitioners. He has since written several textbooks for athletic trainers, including one with David O. Draper, Therapeutic Modalities: The Art and Science, Second Edition, published in 2013. They include an extensive and well-referenced discussion supporting the proper use of cryotherapy in the treatment of acute, subacute, and chronic injuries.
In recent years, a significant anticryotherapy movement has emerged, arguing that enough research now exists to show that cryotherapy applications delay healing of acute injuries. Gabe Mirkin, MD, is one of the experts who has published commentary against the use of ice. Mirkin takes credit for coining the acronym RICE when he and coauthor Marshall Hoffman published The Sports Medicine Book (1978). In 2015, Mirkin walked back his thinking on RICE, especially the use of ice to control inflammation.
Dr. Mirkin refers to a 2004 review of 22 studies that found almost no evidence that ice and compression promoted faster healing. The study authors concluded,
There was little evidence to suggest that the addition of ice to compression had any significant effect, but this was restricted to treatment of hospital inpatients. Few studies assessed the effectiveness of ice on closed soft tissue injury, and there was no evidence of an optimal mode or duration of treatment. (Bleakley, McDonough, and MacAuley 2004, p. 220)
It's important to note that this review did not find evidence that ice and compression delayed healing.
Two other popular proponents of the no-ice approach for acute injury are Gary Reinl, the author of Iced! The Illusionary Treatment Option (2014), and Josh Stone, ATC, CSCS, who has written extensively on his blog on the detrimental effects of cryotherapy for acute injuries (stoneathleticmedicine.com). Both of these authors provide ample research to support their conclusions.
The anti-ice proponents argue that, although ice may provide some pain relief, it delays healing by interrupting the inflammatory process, by interfering with the removal of edema from the injured area, and by preventing or slowing the release of the hormone known as insulin-like growth factor (IGF-1). IGF-1 stimulates cell growth and proliferation and inhibits cell death.
In a 2011 animal-based experiment, the effects of cryotherapy on healing after a skeletal muscle crush injury were studied (Takagi et al.). Immediately following the lab-induced injury, the experimental rats were randomly divided into no-ice and icing groups. In the latter, crushed-ice packs were applied for 20 minutes. The authors then microscopically and physiologically analyzed the healing progression of the injured muscles at 12 hours and then every day for the first 7 days and at 14 and 28 days after the injury. The results of the study showed that “icing applied soon after the injury not only considerably retarded muscle regeneration but also induced impairment of muscle regeneration along with excessive collagen deposition” (Takagi et al. 2011, p. 388). The takeaway from these results is that cryotherapy applied immediately postinjury has both short-term and long-term negative effects on muscle healing. It appears that the temporary pain relief afforded by using ice for 20 minutes creates detrimental effects on the muscle-healing process and may produce weaker and more fibrotic muscle tissue.
A separate study also indicates that icing may produce fibrosis during the healing process (Shibaguchi et al. 2016). The researchers applied ice for 20 minutes to injured rats, then applied heat stress (107°F for 30 min) on the experimental group every other day for the next 14 days. They found that the recovery of muscle mass, protein content, and muscle fiber size toward the levels of the uninjured control group was greater in the heat-stress group and that fibrosis increased in the icing-only group. These findings indicate that using heat on acute injuries, previously anathema, may instead be a viable intervention to promote complete healing of injured skeletal muscles.
As the ice versus no-ice debate continues, practitioners are using several alternative interventions to promote more efficient recovery from acute injury. These may include treatments based on traditional Chinese medicine, or variations on the RICE protocol.
Traditional Chinese Medicine Traditional Chinese medicine (TCM) has always eschewed the use of ice for treating acute injuries. According to Bisio (2004), TCM sports medicine practitioners believe that cold and damp invades the injured area, congesting and congealing the blood and qi (also written as chi and meaning vital energy). This stagnation leads to a cascade of effects, including chronic swelling that is hard to disperse and “an arthritic type of pain that often increases with weather changes and is difficult to treat” (Bisio 2004, p. 23). TCM offers several alternative interventions to treat the swelling and inflammation of acute injuries. These include acupuncture, herbal poultices, massage with special liniments, cupping and bleeding, and oral herbal remedies.
POLICE Bleakley and colleagues (2012) have proposed POLICE(protection, optimal loading, ice, compression, and elevation). According to this editorial,
POLICE . . . is not simply a formula but a reminder to clinicians to think differently and seek out new and innovative strategies for safe and effective loading in acute soft tissue injury management. Optimal loading is an umbrella term for any mechanotherapy intervention and includes a wide range of manual techniques currently available; indeed, the term may include manual techniques such as massage refined to maximise the mechano-effect… POLICE is not just an acronym to guide management but a stimulus to a new field of research. It is important that this research includes more rigorous examination of the role of ICE in acute injury management. Currently, cold-induced analgesia and the assurance and support provided by compression and elevation are enough to retain ICE within the acronym. (2012, p. 220)
MEAT MEAT (movement, exercise, analgesia, treatment) has emerged as another alternative to RICE for treating acute soft tissue injuries, especially injuries to tendons and ligaments. The rationale for using MEAT is that early movement and appropriate exercise is better for recovery than immobilization. Buckwalter (1995) discussed the importance of controlled early resumption of activities to promote restoration of ligament and tendon function.
A systematic review of 21 studies was done in 2002 to compare the results of immobilization versus functional treatment for acute lateral ankle sprains. The reviewers concluded that
Functional treatment appears to be the favourable strategy for treating acute ankle sprains when compared with immobilisation. However, these results should be interpreted with caution, as most of the differences are not significant after exclusion of the low-quality trials. Many trials were poorly reported and there was variety amongst the functional treatments evaluated. (Kerkhoffs et al. 2002, p. 2)
As physicians, sports medicine practitioners, and researchers continue to explore these issues, it's important to remember that while each of these approaches has pros and cons, the quality of the research comparing these interventions leaves a lot to be desired. At this point in the debate, however, it appears safe to assume the cryotherapy portion of RICE is ill-advised, and movement is preferred over immobilization. The challenge for sports massage therapists is to understand, and to help their athletes understand, the rationale for not using ice, especially those athletes with a long history of using ice as their recovery modality of choice.
Understanding the science of pain
An explosion of research on pain in recent years has led to new insights into, as well as great confusion about, the origins of pain, the connections between injury and pain, and the psychological and social contributions to the perception of pain.
An explosion of research on pain in recent years has led to new insights into, as well as great confusion about, the origins of pain, the connections between injury and pain, and the psychological and social contributions to the perception of pain. This broadened knowledge of the complexity of pain has also affected the way manual therapy practitioners approach their work with clients.
By contrast, as the understanding of the mechanisms of pain perception and pain generation has progressed, many researchers and practitioners have reframed the discussion of pain in relation to injury by emphasizing that pain is a complex experience, involving many parts of the brain, and that pain perception is influenced by psychosocial factors that include previous pain experiences, thoughts and feelings about previous pain experiences, emotional states, and even personal relationships. These elements of the pain experience have been recognized for years but have been downplayed in favor of a pathomechanical model of pain that described the stimulation of pain receptors in the tissue when an injury or insult occurred there. These receptors would then stimulate the pain region of the brain, and pain would be felt. It now appears that pain receptors do not exist, but nociceptive receptors do and are stimulated by a variety of noxious stimuli, including pressure, temperature, and inflammatory markers. These receptors send signals to the brain via the spinal cord, and the brain evaluates the signal and determines whether the input is pain or not, and then outputs either the sensation of pain or something else, such as an increase in pressure or a feeling of additional warmth. What this means in practical terms for practitioners is that pain intensity does not necessarily correlate with tissue damage. Minor injuries can feel extremely painful, and severe injuries may occur with very little pain. This response is modulated by the brain and is dependent on all the biopsychosocial factors influencing the brain's final output.
In chronic pain conditions, a neural pathway can become sensitized by repeated nociceptive stimulation so that even minor noxious input can trigger output from the brain that causes the patient to feel pain. On the other hand, this does not mean that pain intensity never correlates directly with the amount of tissue damage, and it's critical for practitioners and patients to stay mindful of this fact.
Growing evidence indicates that incorporating pain neuroscience education (PNE) with manual treatment is efficacious for reducing chronic pain. The intent of PNE is to help shift the client's focus away from “my tissues are painful, so they must be injured” to realizing that the brain's perception and interpretation of stimuli emanating from the tissues may not always accurately reflect the degree of tissue damage. Encouraging a client to shift their focus away from the idea that their pain is caused by specific tissue damage has been shown to reduce chronic pain and, more importantly, to reduce pain catastrophization (magnifying the pain and feeling helpless in the presence of pain).
As practitioners and patients read and hear more about the new pain science, they may make the incorrect assumption that the oversimplified phrase “pain is in the brain” means that pain is all in your head. It's incumbent on the professionals to reassure patients that they're not making it all up (as has been the unfortunate experience of many patients). As Whitney Lowe, massage educator and author, has written,
I think one of the biggest obstacles and challenges for those who are carrying the torch of the emerging pain science specialty is to understand how to introduce these ideas to those for whom this view is new. Too often I have seen and heard pain science enthusiasts speak to others with condescension and arrogance. As a teacher I clearly recognize how that produces an immediate degree of defensiveness in a student and that is a significant obstacle to learning. (Lowe 2017, p. 1)
Because knowledge about pain perception continues to emerge and evolve, the other clear message for practitioners and patients is that our prior knowledge and experience about pain and treating patients in pain is not suddenly obsolete or ineffective. “It isn't necessary to throw out all of the valuable learning and clinical experience we have already built upon. But maybe we look at these things through a different set of glasses” (Lowe 2017, p. 1). It is incumbent on sports massage practitioners to discuss with clients the current research about pain and how those research findings will affect the treatment strategies proposed in their particular case.
What is tennis elbow?
Tennis elbow (lateral epicondylitis) is the most common overuse injury of the elbow, resulting from repetitive strain to the common extensor tendons of the wrist.
Tennis elbow (lateral epicondylitis) is the most common overuse injury of the elbow, resulting from repetitive strain to the common extensor tendons of the wrist. Although this condition is named for a sport in which it's common, it can also occur in other activities that involve repetitive stress on the wrist extensors.
Signs and Symptoms
Lateral epicondylitis (or epicondylosis if no inflammation is present) is characterized by a deep ache at the lateral epicondyle that is made worse by activity. Other symptoms may include pain at the lateral elbow, mild to moderate swelling, and limitation of wrist extension or flexion. The athlete may also experience sudden twinges of extreme pain. In well-advanced cases, sharp pain is often reported when gripping a racket or even shaking hands.
Typical History
Tennis elbow, like most overuse conditions, develops gradually over several months. It may flare up suddenly as a result of increased intensity of activity, such as competing in a tennis tournament. If the injury is not the result of a racket sport, look for repetitive motion in the client's daily activities.
Relevant Anatomy
In most cases, the primary injury is tendinopathy of the extensor carpi radialis brevis (ECRB) tendon, just distal to its attachment on the lateral epicondyle. The rest of the wrist and finger extensors may be affected by the presence of tennis elbow, either by becoming hypertonic or by becoming inhibited because of pain. See figure 7.12 for illustrations indicating the wrist and finger extensors.
Figure 7.12 Wrist and finger extensors.
Extensor Carpi Radialis Brevis
The extensor carpi radialis brevis (ECRB) originates from the common extensor tendon at the lateral epicondyle of the humerus and inserts into the dorsoradial aspect of the base of the third metacarpal bone. Actions include extension of the wrist (with the ECR longus and ulnaris) and assisting radial deviation (abduction).
Extensor Carpi Radialis Longus
The extensor carpi radialis longus (ECRL)originates on the distal third of the lateral supracondylar ridge of the humerus, lying between the origin of the brachioradialis and the lateral epicondyle and inserts into the dorsoradial aspect of the base of the second metacarpal bone. Actions include extending the wrist (along with the ECR brevis and ulnaris) and assisting radial deviation (along with the flexor carpi radialis).
Supinator
The supinator originates from the posterior ulna, the lateral epicondyle, ligaments of the elbow and radioulnar joint, and the anterior capsule of the humeroulnar joint and inserts into the anterolateral aspect of the radius, just distal to the insertion of the biceps brachii. Actions include primary supinator of the hand and forearm; with the elbow flexed, the biceps brachii assists supination and assists elbow flexion when the hand is in neutral.
The radial nerve passes through the supinator muscle, and radial nerve entrapment may create symptoms similar to tennis elbow. Trigger points in the supinator may create referred pain that mimics tennis elbow and can be deactivated as part of the overall treatment for tennis elbow. Fun fact: Because supination is a stronger action than pronation, bolts and screws are designed to tighten by supination of the right forearm (righty-tighty, lefty-loosey).
Anconeus
The anconeus originates from the posterior aspect of the lateral epicondyle of the humerus and inserts into the lateral aspect of the olecranon process and the proximal posterior ulna. Actions include assisting triceps in extension of the elbow and assisting stabilization of the elbow joint during supination and pronation. The anconeus is thought to be secondarily involved in chronic cases of tennis elbow when additional stress placed on it results in compensation or inhibition of the extensor carpi radialis brevis.
Brachioradialis
The brachioradialis originates from the upper two-thirds of the supracondylar ridge of the humerus and inserts into the lateral radius, just proximal to the styloid process. Actions include flexion at the elbow, especially when the hand is in the neutral position; it may assist resisted pronation and supination. The brachioradialis may be secondarily involved with tennis elbow because of its proximity to the extensor carpi radialis longus.
Assessment
Observation
In severe cases, visible swelling over the lateral epicondyle may be present.
ROM Assessment
Active motion at the wrist consists of flexion, extension, abduction (radial deviation), and adduction (ulnar deviation). Depending on the severity of the injury, these motions may or may not cause pain. Passive motion is generally pain free except for wrist flexion, which may stretch painful tissues on the extensor side of the forearm, especially with the elbow extended.
Resisted extension of the wrist is painful. Resisted radial deviation may also be painful.
Manual Resistive Tests
The athlete, sitting or standing, places her wrist in neutral, forearm pronated. The examiner grasps the lateral elbow with one hand, and the other hand provides resistance as the athlete attempts to extend the wrist (see figure 7.13). This isometric contraction should begin slowly and build to a strong engagement of the target muscles. With the elbow flexed, the test will engage the ECR brevis more fully; with the elbow extended, the test will focus more on the ECR longus. Pain or weakness is a positive finding. Resisted extension of the middle finger (also known as Maudsley's test) is commonly positive for pain or weakness in tennis elbow (Fairbank and Corlett 2002) (see figure 7.14). If no pain occurs, the examination widens to include the other muscles that might cause lateral epicondyle pain, such as the supinator, brachioradialis, and anconeus.
Figure 7.13 Resisted wrist extension test: with (a) elbow flexed and (b) elbow straight.
Figure 7.14 Middle-finger extension test.
Cryotherapy for acute injuries
Athletes and sports practitioners have used ice, or cryotherapy, to control the pain and inflammation of acute and chronic injuries for generations.
Athletes and sports practitioners have used ice, or cryotherapy, to control the pain and inflammation of acute and chronic injuries for generations. There is broad agreement among practitioners that inflammation is a necessary component of the healing process, but excessive or prolonged inflammation may delay or disrupt the completion of the healing process. Cryotherapy has traditionally been used to limit but not eliminate inflammation, as well as to control swelling and reduce pain.
Kenneth Knight, PhD, ATC, published Cryotherapy in Sport Injury Management in 1995, and it quickly became the go-to cryotherapy resource for practitioners. He has since written several textbooks for athletic trainers, including one with David O. Draper, Therapeutic Modalities: The Art and Science, Second Edition, published in 2013. They include an extensive and well-referenced discussion supporting the proper use of cryotherapy in the treatment of acute, subacute, and chronic injuries.
In recent years, a significant anticryotherapy movement has emerged, arguing that enough research now exists to show that cryotherapy applications delay healing of acute injuries. Gabe Mirkin, MD, is one of the experts who has published commentary against the use of ice. Mirkin takes credit for coining the acronym RICE when he and coauthor Marshall Hoffman published The Sports Medicine Book (1978). In 2015, Mirkin walked back his thinking on RICE, especially the use of ice to control inflammation.
Dr. Mirkin refers to a 2004 review of 22 studies that found almost no evidence that ice and compression promoted faster healing. The study authors concluded,
There was little evidence to suggest that the addition of ice to compression had any significant effect, but this was restricted to treatment of hospital inpatients. Few studies assessed the effectiveness of ice on closed soft tissue injury, and there was no evidence of an optimal mode or duration of treatment. (Bleakley, McDonough, and MacAuley 2004, p. 220)
It's important to note that this review did not find evidence that ice and compression delayed healing.
Two other popular proponents of the no-ice approach for acute injury are Gary Reinl, the author of Iced! The Illusionary Treatment Option (2014), and Josh Stone, ATC, CSCS, who has written extensively on his blog on the detrimental effects of cryotherapy for acute injuries (stoneathleticmedicine.com). Both of these authors provide ample research to support their conclusions.
The anti-ice proponents argue that, although ice may provide some pain relief, it delays healing by interrupting the inflammatory process, by interfering with the removal of edema from the injured area, and by preventing or slowing the release of the hormone known as insulin-like growth factor (IGF-1). IGF-1 stimulates cell growth and proliferation and inhibits cell death.
In a 2011 animal-based experiment, the effects of cryotherapy on healing after a skeletal muscle crush injury were studied (Takagi et al.). Immediately following the lab-induced injury, the experimental rats were randomly divided into no-ice and icing groups. In the latter, crushed-ice packs were applied for 20 minutes. The authors then microscopically and physiologically analyzed the healing progression of the injured muscles at 12 hours and then every day for the first 7 days and at 14 and 28 days after the injury. The results of the study showed that “icing applied soon after the injury not only considerably retarded muscle regeneration but also induced impairment of muscle regeneration along with excessive collagen deposition” (Takagi et al. 2011, p. 388). The takeaway from these results is that cryotherapy applied immediately postinjury has both short-term and long-term negative effects on muscle healing. It appears that the temporary pain relief afforded by using ice for 20 minutes creates detrimental effects on the muscle-healing process and may produce weaker and more fibrotic muscle tissue.
A separate study also indicates that icing may produce fibrosis during the healing process (Shibaguchi et al. 2016). The researchers applied ice for 20 minutes to injured rats, then applied heat stress (107°F for 30 min) on the experimental group every other day for the next 14 days. They found that the recovery of muscle mass, protein content, and muscle fiber size toward the levels of the uninjured control group was greater in the heat-stress group and that fibrosis increased in the icing-only group. These findings indicate that using heat on acute injuries, previously anathema, may instead be a viable intervention to promote complete healing of injured skeletal muscles.
As the ice versus no-ice debate continues, practitioners are using several alternative interventions to promote more efficient recovery from acute injury. These may include treatments based on traditional Chinese medicine, or variations on the RICE protocol.
Traditional Chinese Medicine Traditional Chinese medicine (TCM) has always eschewed the use of ice for treating acute injuries. According to Bisio (2004), TCM sports medicine practitioners believe that cold and damp invades the injured area, congesting and congealing the blood and qi (also written as chi and meaning vital energy). This stagnation leads to a cascade of effects, including chronic swelling that is hard to disperse and “an arthritic type of pain that often increases with weather changes and is difficult to treat” (Bisio 2004, p. 23). TCM offers several alternative interventions to treat the swelling and inflammation of acute injuries. These include acupuncture, herbal poultices, massage with special liniments, cupping and bleeding, and oral herbal remedies.
POLICE Bleakley and colleagues (2012) have proposed POLICE(protection, optimal loading, ice, compression, and elevation). According to this editorial,
POLICE . . . is not simply a formula but a reminder to clinicians to think differently and seek out new and innovative strategies for safe and effective loading in acute soft tissue injury management. Optimal loading is an umbrella term for any mechanotherapy intervention and includes a wide range of manual techniques currently available; indeed, the term may include manual techniques such as massage refined to maximise the mechano-effect… POLICE is not just an acronym to guide management but a stimulus to a new field of research. It is important that this research includes more rigorous examination of the role of ICE in acute injury management. Currently, cold-induced analgesia and the assurance and support provided by compression and elevation are enough to retain ICE within the acronym. (2012, p. 220)
MEAT MEAT (movement, exercise, analgesia, treatment) has emerged as another alternative to RICE for treating acute soft tissue injuries, especially injuries to tendons and ligaments. The rationale for using MEAT is that early movement and appropriate exercise is better for recovery than immobilization. Buckwalter (1995) discussed the importance of controlled early resumption of activities to promote restoration of ligament and tendon function.
A systematic review of 21 studies was done in 2002 to compare the results of immobilization versus functional treatment for acute lateral ankle sprains. The reviewers concluded that
Functional treatment appears to be the favourable strategy for treating acute ankle sprains when compared with immobilisation. However, these results should be interpreted with caution, as most of the differences are not significant after exclusion of the low-quality trials. Many trials were poorly reported and there was variety amongst the functional treatments evaluated. (Kerkhoffs et al. 2002, p. 2)
As physicians, sports medicine practitioners, and researchers continue to explore these issues, it's important to remember that while each of these approaches has pros and cons, the quality of the research comparing these interventions leaves a lot to be desired. At this point in the debate, however, it appears safe to assume the cryotherapy portion of RICE is ill-advised, and movement is preferred over immobilization. The challenge for sports massage therapists is to understand, and to help their athletes understand, the rationale for not using ice, especially those athletes with a long history of using ice as their recovery modality of choice.
Understanding the science of pain
An explosion of research on pain in recent years has led to new insights into, as well as great confusion about, the origins of pain, the connections between injury and pain, and the psychological and social contributions to the perception of pain.
An explosion of research on pain in recent years has led to new insights into, as well as great confusion about, the origins of pain, the connections between injury and pain, and the psychological and social contributions to the perception of pain. This broadened knowledge of the complexity of pain has also affected the way manual therapy practitioners approach their work with clients.
By contrast, as the understanding of the mechanisms of pain perception and pain generation has progressed, many researchers and practitioners have reframed the discussion of pain in relation to injury by emphasizing that pain is a complex experience, involving many parts of the brain, and that pain perception is influenced by psychosocial factors that include previous pain experiences, thoughts and feelings about previous pain experiences, emotional states, and even personal relationships. These elements of the pain experience have been recognized for years but have been downplayed in favor of a pathomechanical model of pain that described the stimulation of pain receptors in the tissue when an injury or insult occurred there. These receptors would then stimulate the pain region of the brain, and pain would be felt. It now appears that pain receptors do not exist, but nociceptive receptors do and are stimulated by a variety of noxious stimuli, including pressure, temperature, and inflammatory markers. These receptors send signals to the brain via the spinal cord, and the brain evaluates the signal and determines whether the input is pain or not, and then outputs either the sensation of pain or something else, such as an increase in pressure or a feeling of additional warmth. What this means in practical terms for practitioners is that pain intensity does not necessarily correlate with tissue damage. Minor injuries can feel extremely painful, and severe injuries may occur with very little pain. This response is modulated by the brain and is dependent on all the biopsychosocial factors influencing the brain's final output.
In chronic pain conditions, a neural pathway can become sensitized by repeated nociceptive stimulation so that even minor noxious input can trigger output from the brain that causes the patient to feel pain. On the other hand, this does not mean that pain intensity never correlates directly with the amount of tissue damage, and it's critical for practitioners and patients to stay mindful of this fact.
Growing evidence indicates that incorporating pain neuroscience education (PNE) with manual treatment is efficacious for reducing chronic pain. The intent of PNE is to help shift the client's focus away from “my tissues are painful, so they must be injured” to realizing that the brain's perception and interpretation of stimuli emanating from the tissues may not always accurately reflect the degree of tissue damage. Encouraging a client to shift their focus away from the idea that their pain is caused by specific tissue damage has been shown to reduce chronic pain and, more importantly, to reduce pain catastrophization (magnifying the pain and feeling helpless in the presence of pain).
As practitioners and patients read and hear more about the new pain science, they may make the incorrect assumption that the oversimplified phrase “pain is in the brain” means that pain is all in your head. It's incumbent on the professionals to reassure patients that they're not making it all up (as has been the unfortunate experience of many patients). As Whitney Lowe, massage educator and author, has written,
I think one of the biggest obstacles and challenges for those who are carrying the torch of the emerging pain science specialty is to understand how to introduce these ideas to those for whom this view is new. Too often I have seen and heard pain science enthusiasts speak to others with condescension and arrogance. As a teacher I clearly recognize how that produces an immediate degree of defensiveness in a student and that is a significant obstacle to learning. (Lowe 2017, p. 1)
Because knowledge about pain perception continues to emerge and evolve, the other clear message for practitioners and patients is that our prior knowledge and experience about pain and treating patients in pain is not suddenly obsolete or ineffective. “It isn't necessary to throw out all of the valuable learning and clinical experience we have already built upon. But maybe we look at these things through a different set of glasses” (Lowe 2017, p. 1). It is incumbent on sports massage practitioners to discuss with clients the current research about pain and how those research findings will affect the treatment strategies proposed in their particular case.
What is tennis elbow?
Tennis elbow (lateral epicondylitis) is the most common overuse injury of the elbow, resulting from repetitive strain to the common extensor tendons of the wrist.
Tennis elbow (lateral epicondylitis) is the most common overuse injury of the elbow, resulting from repetitive strain to the common extensor tendons of the wrist. Although this condition is named for a sport in which it's common, it can also occur in other activities that involve repetitive stress on the wrist extensors.
Signs and Symptoms
Lateral epicondylitis (or epicondylosis if no inflammation is present) is characterized by a deep ache at the lateral epicondyle that is made worse by activity. Other symptoms may include pain at the lateral elbow, mild to moderate swelling, and limitation of wrist extension or flexion. The athlete may also experience sudden twinges of extreme pain. In well-advanced cases, sharp pain is often reported when gripping a racket or even shaking hands.
Typical History
Tennis elbow, like most overuse conditions, develops gradually over several months. It may flare up suddenly as a result of increased intensity of activity, such as competing in a tennis tournament. If the injury is not the result of a racket sport, look for repetitive motion in the client's daily activities.
Relevant Anatomy
In most cases, the primary injury is tendinopathy of the extensor carpi radialis brevis (ECRB) tendon, just distal to its attachment on the lateral epicondyle. The rest of the wrist and finger extensors may be affected by the presence of tennis elbow, either by becoming hypertonic or by becoming inhibited because of pain. See figure 7.12 for illustrations indicating the wrist and finger extensors.
Figure 7.12 Wrist and finger extensors.
Extensor Carpi Radialis Brevis
The extensor carpi radialis brevis (ECRB) originates from the common extensor tendon at the lateral epicondyle of the humerus and inserts into the dorsoradial aspect of the base of the third metacarpal bone. Actions include extension of the wrist (with the ECR longus and ulnaris) and assisting radial deviation (abduction).
Extensor Carpi Radialis Longus
The extensor carpi radialis longus (ECRL)originates on the distal third of the lateral supracondylar ridge of the humerus, lying between the origin of the brachioradialis and the lateral epicondyle and inserts into the dorsoradial aspect of the base of the second metacarpal bone. Actions include extending the wrist (along with the ECR brevis and ulnaris) and assisting radial deviation (along with the flexor carpi radialis).
Supinator
The supinator originates from the posterior ulna, the lateral epicondyle, ligaments of the elbow and radioulnar joint, and the anterior capsule of the humeroulnar joint and inserts into the anterolateral aspect of the radius, just distal to the insertion of the biceps brachii. Actions include primary supinator of the hand and forearm; with the elbow flexed, the biceps brachii assists supination and assists elbow flexion when the hand is in neutral.
The radial nerve passes through the supinator muscle, and radial nerve entrapment may create symptoms similar to tennis elbow. Trigger points in the supinator may create referred pain that mimics tennis elbow and can be deactivated as part of the overall treatment for tennis elbow. Fun fact: Because supination is a stronger action than pronation, bolts and screws are designed to tighten by supination of the right forearm (righty-tighty, lefty-loosey).
Anconeus
The anconeus originates from the posterior aspect of the lateral epicondyle of the humerus and inserts into the lateral aspect of the olecranon process and the proximal posterior ulna. Actions include assisting triceps in extension of the elbow and assisting stabilization of the elbow joint during supination and pronation. The anconeus is thought to be secondarily involved in chronic cases of tennis elbow when additional stress placed on it results in compensation or inhibition of the extensor carpi radialis brevis.
Brachioradialis
The brachioradialis originates from the upper two-thirds of the supracondylar ridge of the humerus and inserts into the lateral radius, just proximal to the styloid process. Actions include flexion at the elbow, especially when the hand is in the neutral position; it may assist resisted pronation and supination. The brachioradialis may be secondarily involved with tennis elbow because of its proximity to the extensor carpi radialis longus.
Assessment
Observation
In severe cases, visible swelling over the lateral epicondyle may be present.
ROM Assessment
Active motion at the wrist consists of flexion, extension, abduction (radial deviation), and adduction (ulnar deviation). Depending on the severity of the injury, these motions may or may not cause pain. Passive motion is generally pain free except for wrist flexion, which may stretch painful tissues on the extensor side of the forearm, especially with the elbow extended.
Resisted extension of the wrist is painful. Resisted radial deviation may also be painful.
Manual Resistive Tests
The athlete, sitting or standing, places her wrist in neutral, forearm pronated. The examiner grasps the lateral elbow with one hand, and the other hand provides resistance as the athlete attempts to extend the wrist (see figure 7.13). This isometric contraction should begin slowly and build to a strong engagement of the target muscles. With the elbow flexed, the test will engage the ECR brevis more fully; with the elbow extended, the test will focus more on the ECR longus. Pain or weakness is a positive finding. Resisted extension of the middle finger (also known as Maudsley's test) is commonly positive for pain or weakness in tennis elbow (Fairbank and Corlett 2002) (see figure 7.14). If no pain occurs, the examination widens to include the other muscles that might cause lateral epicondyle pain, such as the supinator, brachioradialis, and anconeus.
Figure 7.13 Resisted wrist extension test: with (a) elbow flexed and (b) elbow straight.
Figure 7.14 Middle-finger extension test.
Cryotherapy for acute injuries
Athletes and sports practitioners have used ice, or cryotherapy, to control the pain and inflammation of acute and chronic injuries for generations.
Athletes and sports practitioners have used ice, or cryotherapy, to control the pain and inflammation of acute and chronic injuries for generations. There is broad agreement among practitioners that inflammation is a necessary component of the healing process, but excessive or prolonged inflammation may delay or disrupt the completion of the healing process. Cryotherapy has traditionally been used to limit but not eliminate inflammation, as well as to control swelling and reduce pain.
Kenneth Knight, PhD, ATC, published Cryotherapy in Sport Injury Management in 1995, and it quickly became the go-to cryotherapy resource for practitioners. He has since written several textbooks for athletic trainers, including one with David O. Draper, Therapeutic Modalities: The Art and Science, Second Edition, published in 2013. They include an extensive and well-referenced discussion supporting the proper use of cryotherapy in the treatment of acute, subacute, and chronic injuries.
In recent years, a significant anticryotherapy movement has emerged, arguing that enough research now exists to show that cryotherapy applications delay healing of acute injuries. Gabe Mirkin, MD, is one of the experts who has published commentary against the use of ice. Mirkin takes credit for coining the acronym RICE when he and coauthor Marshall Hoffman published The Sports Medicine Book (1978). In 2015, Mirkin walked back his thinking on RICE, especially the use of ice to control inflammation.
Dr. Mirkin refers to a 2004 review of 22 studies that found almost no evidence that ice and compression promoted faster healing. The study authors concluded,
There was little evidence to suggest that the addition of ice to compression had any significant effect, but this was restricted to treatment of hospital inpatients. Few studies assessed the effectiveness of ice on closed soft tissue injury, and there was no evidence of an optimal mode or duration of treatment. (Bleakley, McDonough, and MacAuley 2004, p. 220)
It's important to note that this review did not find evidence that ice and compression delayed healing.
Two other popular proponents of the no-ice approach for acute injury are Gary Reinl, the author of Iced! The Illusionary Treatment Option (2014), and Josh Stone, ATC, CSCS, who has written extensively on his blog on the detrimental effects of cryotherapy for acute injuries (stoneathleticmedicine.com). Both of these authors provide ample research to support their conclusions.
The anti-ice proponents argue that, although ice may provide some pain relief, it delays healing by interrupting the inflammatory process, by interfering with the removal of edema from the injured area, and by preventing or slowing the release of the hormone known as insulin-like growth factor (IGF-1). IGF-1 stimulates cell growth and proliferation and inhibits cell death.
In a 2011 animal-based experiment, the effects of cryotherapy on healing after a skeletal muscle crush injury were studied (Takagi et al.). Immediately following the lab-induced injury, the experimental rats were randomly divided into no-ice and icing groups. In the latter, crushed-ice packs were applied for 20 minutes. The authors then microscopically and physiologically analyzed the healing progression of the injured muscles at 12 hours and then every day for the first 7 days and at 14 and 28 days after the injury. The results of the study showed that “icing applied soon after the injury not only considerably retarded muscle regeneration but also induced impairment of muscle regeneration along with excessive collagen deposition” (Takagi et al. 2011, p. 388). The takeaway from these results is that cryotherapy applied immediately postinjury has both short-term and long-term negative effects on muscle healing. It appears that the temporary pain relief afforded by using ice for 20 minutes creates detrimental effects on the muscle-healing process and may produce weaker and more fibrotic muscle tissue.
A separate study also indicates that icing may produce fibrosis during the healing process (Shibaguchi et al. 2016). The researchers applied ice for 20 minutes to injured rats, then applied heat stress (107°F for 30 min) on the experimental group every other day for the next 14 days. They found that the recovery of muscle mass, protein content, and muscle fiber size toward the levels of the uninjured control group was greater in the heat-stress group and that fibrosis increased in the icing-only group. These findings indicate that using heat on acute injuries, previously anathema, may instead be a viable intervention to promote complete healing of injured skeletal muscles.
As the ice versus no-ice debate continues, practitioners are using several alternative interventions to promote more efficient recovery from acute injury. These may include treatments based on traditional Chinese medicine, or variations on the RICE protocol.
Traditional Chinese Medicine Traditional Chinese medicine (TCM) has always eschewed the use of ice for treating acute injuries. According to Bisio (2004), TCM sports medicine practitioners believe that cold and damp invades the injured area, congesting and congealing the blood and qi (also written as chi and meaning vital energy). This stagnation leads to a cascade of effects, including chronic swelling that is hard to disperse and “an arthritic type of pain that often increases with weather changes and is difficult to treat” (Bisio 2004, p. 23). TCM offers several alternative interventions to treat the swelling and inflammation of acute injuries. These include acupuncture, herbal poultices, massage with special liniments, cupping and bleeding, and oral herbal remedies.
POLICE Bleakley and colleagues (2012) have proposed POLICE(protection, optimal loading, ice, compression, and elevation). According to this editorial,
POLICE . . . is not simply a formula but a reminder to clinicians to think differently and seek out new and innovative strategies for safe and effective loading in acute soft tissue injury management. Optimal loading is an umbrella term for any mechanotherapy intervention and includes a wide range of manual techniques currently available; indeed, the term may include manual techniques such as massage refined to maximise the mechano-effect… POLICE is not just an acronym to guide management but a stimulus to a new field of research. It is important that this research includes more rigorous examination of the role of ICE in acute injury management. Currently, cold-induced analgesia and the assurance and support provided by compression and elevation are enough to retain ICE within the acronym. (2012, p. 220)
MEAT MEAT (movement, exercise, analgesia, treatment) has emerged as another alternative to RICE for treating acute soft tissue injuries, especially injuries to tendons and ligaments. The rationale for using MEAT is that early movement and appropriate exercise is better for recovery than immobilization. Buckwalter (1995) discussed the importance of controlled early resumption of activities to promote restoration of ligament and tendon function.
A systematic review of 21 studies was done in 2002 to compare the results of immobilization versus functional treatment for acute lateral ankle sprains. The reviewers concluded that
Functional treatment appears to be the favourable strategy for treating acute ankle sprains when compared with immobilisation. However, these results should be interpreted with caution, as most of the differences are not significant after exclusion of the low-quality trials. Many trials were poorly reported and there was variety amongst the functional treatments evaluated. (Kerkhoffs et al. 2002, p. 2)
As physicians, sports medicine practitioners, and researchers continue to explore these issues, it's important to remember that while each of these approaches has pros and cons, the quality of the research comparing these interventions leaves a lot to be desired. At this point in the debate, however, it appears safe to assume the cryotherapy portion of RICE is ill-advised, and movement is preferred over immobilization. The challenge for sports massage therapists is to understand, and to help their athletes understand, the rationale for not using ice, especially those athletes with a long history of using ice as their recovery modality of choice.
Understanding the science of pain
An explosion of research on pain in recent years has led to new insights into, as well as great confusion about, the origins of pain, the connections between injury and pain, and the psychological and social contributions to the perception of pain.
An explosion of research on pain in recent years has led to new insights into, as well as great confusion about, the origins of pain, the connections between injury and pain, and the psychological and social contributions to the perception of pain. This broadened knowledge of the complexity of pain has also affected the way manual therapy practitioners approach their work with clients.
By contrast, as the understanding of the mechanisms of pain perception and pain generation has progressed, many researchers and practitioners have reframed the discussion of pain in relation to injury by emphasizing that pain is a complex experience, involving many parts of the brain, and that pain perception is influenced by psychosocial factors that include previous pain experiences, thoughts and feelings about previous pain experiences, emotional states, and even personal relationships. These elements of the pain experience have been recognized for years but have been downplayed in favor of a pathomechanical model of pain that described the stimulation of pain receptors in the tissue when an injury or insult occurred there. These receptors would then stimulate the pain region of the brain, and pain would be felt. It now appears that pain receptors do not exist, but nociceptive receptors do and are stimulated by a variety of noxious stimuli, including pressure, temperature, and inflammatory markers. These receptors send signals to the brain via the spinal cord, and the brain evaluates the signal and determines whether the input is pain or not, and then outputs either the sensation of pain or something else, such as an increase in pressure or a feeling of additional warmth. What this means in practical terms for practitioners is that pain intensity does not necessarily correlate with tissue damage. Minor injuries can feel extremely painful, and severe injuries may occur with very little pain. This response is modulated by the brain and is dependent on all the biopsychosocial factors influencing the brain's final output.
In chronic pain conditions, a neural pathway can become sensitized by repeated nociceptive stimulation so that even minor noxious input can trigger output from the brain that causes the patient to feel pain. On the other hand, this does not mean that pain intensity never correlates directly with the amount of tissue damage, and it's critical for practitioners and patients to stay mindful of this fact.
Growing evidence indicates that incorporating pain neuroscience education (PNE) with manual treatment is efficacious for reducing chronic pain. The intent of PNE is to help shift the client's focus away from “my tissues are painful, so they must be injured” to realizing that the brain's perception and interpretation of stimuli emanating from the tissues may not always accurately reflect the degree of tissue damage. Encouraging a client to shift their focus away from the idea that their pain is caused by specific tissue damage has been shown to reduce chronic pain and, more importantly, to reduce pain catastrophization (magnifying the pain and feeling helpless in the presence of pain).
As practitioners and patients read and hear more about the new pain science, they may make the incorrect assumption that the oversimplified phrase “pain is in the brain” means that pain is all in your head. It's incumbent on the professionals to reassure patients that they're not making it all up (as has been the unfortunate experience of many patients). As Whitney Lowe, massage educator and author, has written,
I think one of the biggest obstacles and challenges for those who are carrying the torch of the emerging pain science specialty is to understand how to introduce these ideas to those for whom this view is new. Too often I have seen and heard pain science enthusiasts speak to others with condescension and arrogance. As a teacher I clearly recognize how that produces an immediate degree of defensiveness in a student and that is a significant obstacle to learning. (Lowe 2017, p. 1)
Because knowledge about pain perception continues to emerge and evolve, the other clear message for practitioners and patients is that our prior knowledge and experience about pain and treating patients in pain is not suddenly obsolete or ineffective. “It isn't necessary to throw out all of the valuable learning and clinical experience we have already built upon. But maybe we look at these things through a different set of glasses” (Lowe 2017, p. 1). It is incumbent on sports massage practitioners to discuss with clients the current research about pain and how those research findings will affect the treatment strategies proposed in their particular case.
What is tennis elbow?
Tennis elbow (lateral epicondylitis) is the most common overuse injury of the elbow, resulting from repetitive strain to the common extensor tendons of the wrist.
Tennis elbow (lateral epicondylitis) is the most common overuse injury of the elbow, resulting from repetitive strain to the common extensor tendons of the wrist. Although this condition is named for a sport in which it's common, it can also occur in other activities that involve repetitive stress on the wrist extensors.
Signs and Symptoms
Lateral epicondylitis (or epicondylosis if no inflammation is present) is characterized by a deep ache at the lateral epicondyle that is made worse by activity. Other symptoms may include pain at the lateral elbow, mild to moderate swelling, and limitation of wrist extension or flexion. The athlete may also experience sudden twinges of extreme pain. In well-advanced cases, sharp pain is often reported when gripping a racket or even shaking hands.
Typical History
Tennis elbow, like most overuse conditions, develops gradually over several months. It may flare up suddenly as a result of increased intensity of activity, such as competing in a tennis tournament. If the injury is not the result of a racket sport, look for repetitive motion in the client's daily activities.
Relevant Anatomy
In most cases, the primary injury is tendinopathy of the extensor carpi radialis brevis (ECRB) tendon, just distal to its attachment on the lateral epicondyle. The rest of the wrist and finger extensors may be affected by the presence of tennis elbow, either by becoming hypertonic or by becoming inhibited because of pain. See figure 7.12 for illustrations indicating the wrist and finger extensors.
Figure 7.12 Wrist and finger extensors.
Extensor Carpi Radialis Brevis
The extensor carpi radialis brevis (ECRB) originates from the common extensor tendon at the lateral epicondyle of the humerus and inserts into the dorsoradial aspect of the base of the third metacarpal bone. Actions include extension of the wrist (with the ECR longus and ulnaris) and assisting radial deviation (abduction).
Extensor Carpi Radialis Longus
The extensor carpi radialis longus (ECRL)originates on the distal third of the lateral supracondylar ridge of the humerus, lying between the origin of the brachioradialis and the lateral epicondyle and inserts into the dorsoradial aspect of the base of the second metacarpal bone. Actions include extending the wrist (along with the ECR brevis and ulnaris) and assisting radial deviation (along with the flexor carpi radialis).
Supinator
The supinator originates from the posterior ulna, the lateral epicondyle, ligaments of the elbow and radioulnar joint, and the anterior capsule of the humeroulnar joint and inserts into the anterolateral aspect of the radius, just distal to the insertion of the biceps brachii. Actions include primary supinator of the hand and forearm; with the elbow flexed, the biceps brachii assists supination and assists elbow flexion when the hand is in neutral.
The radial nerve passes through the supinator muscle, and radial nerve entrapment may create symptoms similar to tennis elbow. Trigger points in the supinator may create referred pain that mimics tennis elbow and can be deactivated as part of the overall treatment for tennis elbow. Fun fact: Because supination is a stronger action than pronation, bolts and screws are designed to tighten by supination of the right forearm (righty-tighty, lefty-loosey).
Anconeus
The anconeus originates from the posterior aspect of the lateral epicondyle of the humerus and inserts into the lateral aspect of the olecranon process and the proximal posterior ulna. Actions include assisting triceps in extension of the elbow and assisting stabilization of the elbow joint during supination and pronation. The anconeus is thought to be secondarily involved in chronic cases of tennis elbow when additional stress placed on it results in compensation or inhibition of the extensor carpi radialis brevis.
Brachioradialis
The brachioradialis originates from the upper two-thirds of the supracondylar ridge of the humerus and inserts into the lateral radius, just proximal to the styloid process. Actions include flexion at the elbow, especially when the hand is in the neutral position; it may assist resisted pronation and supination. The brachioradialis may be secondarily involved with tennis elbow because of its proximity to the extensor carpi radialis longus.
Assessment
Observation
In severe cases, visible swelling over the lateral epicondyle may be present.
ROM Assessment
Active motion at the wrist consists of flexion, extension, abduction (radial deviation), and adduction (ulnar deviation). Depending on the severity of the injury, these motions may or may not cause pain. Passive motion is generally pain free except for wrist flexion, which may stretch painful tissues on the extensor side of the forearm, especially with the elbow extended.
Resisted extension of the wrist is painful. Resisted radial deviation may also be painful.
Manual Resistive Tests
The athlete, sitting or standing, places her wrist in neutral, forearm pronated. The examiner grasps the lateral elbow with one hand, and the other hand provides resistance as the athlete attempts to extend the wrist (see figure 7.13). This isometric contraction should begin slowly and build to a strong engagement of the target muscles. With the elbow flexed, the test will engage the ECR brevis more fully; with the elbow extended, the test will focus more on the ECR longus. Pain or weakness is a positive finding. Resisted extension of the middle finger (also known as Maudsley's test) is commonly positive for pain or weakness in tennis elbow (Fairbank and Corlett 2002) (see figure 7.14). If no pain occurs, the examination widens to include the other muscles that might cause lateral epicondyle pain, such as the supinator, brachioradialis, and anconeus.
Figure 7.13 Resisted wrist extension test: with (a) elbow flexed and (b) elbow straight.
Figure 7.14 Middle-finger extension test.
Cryotherapy for acute injuries
Athletes and sports practitioners have used ice, or cryotherapy, to control the pain and inflammation of acute and chronic injuries for generations.
Athletes and sports practitioners have used ice, or cryotherapy, to control the pain and inflammation of acute and chronic injuries for generations. There is broad agreement among practitioners that inflammation is a necessary component of the healing process, but excessive or prolonged inflammation may delay or disrupt the completion of the healing process. Cryotherapy has traditionally been used to limit but not eliminate inflammation, as well as to control swelling and reduce pain.
Kenneth Knight, PhD, ATC, published Cryotherapy in Sport Injury Management in 1995, and it quickly became the go-to cryotherapy resource for practitioners. He has since written several textbooks for athletic trainers, including one with David O. Draper, Therapeutic Modalities: The Art and Science, Second Edition, published in 2013. They include an extensive and well-referenced discussion supporting the proper use of cryotherapy in the treatment of acute, subacute, and chronic injuries.
In recent years, a significant anticryotherapy movement has emerged, arguing that enough research now exists to show that cryotherapy applications delay healing of acute injuries. Gabe Mirkin, MD, is one of the experts who has published commentary against the use of ice. Mirkin takes credit for coining the acronym RICE when he and coauthor Marshall Hoffman published The Sports Medicine Book (1978). In 2015, Mirkin walked back his thinking on RICE, especially the use of ice to control inflammation.
Dr. Mirkin refers to a 2004 review of 22 studies that found almost no evidence that ice and compression promoted faster healing. The study authors concluded,
There was little evidence to suggest that the addition of ice to compression had any significant effect, but this was restricted to treatment of hospital inpatients. Few studies assessed the effectiveness of ice on closed soft tissue injury, and there was no evidence of an optimal mode or duration of treatment. (Bleakley, McDonough, and MacAuley 2004, p. 220)
It's important to note that this review did not find evidence that ice and compression delayed healing.
Two other popular proponents of the no-ice approach for acute injury are Gary Reinl, the author of Iced! The Illusionary Treatment Option (2014), and Josh Stone, ATC, CSCS, who has written extensively on his blog on the detrimental effects of cryotherapy for acute injuries (stoneathleticmedicine.com). Both of these authors provide ample research to support their conclusions.
The anti-ice proponents argue that, although ice may provide some pain relief, it delays healing by interrupting the inflammatory process, by interfering with the removal of edema from the injured area, and by preventing or slowing the release of the hormone known as insulin-like growth factor (IGF-1). IGF-1 stimulates cell growth and proliferation and inhibits cell death.
In a 2011 animal-based experiment, the effects of cryotherapy on healing after a skeletal muscle crush injury were studied (Takagi et al.). Immediately following the lab-induced injury, the experimental rats were randomly divided into no-ice and icing groups. In the latter, crushed-ice packs were applied for 20 minutes. The authors then microscopically and physiologically analyzed the healing progression of the injured muscles at 12 hours and then every day for the first 7 days and at 14 and 28 days after the injury. The results of the study showed that “icing applied soon after the injury not only considerably retarded muscle regeneration but also induced impairment of muscle regeneration along with excessive collagen deposition” (Takagi et al. 2011, p. 388). The takeaway from these results is that cryotherapy applied immediately postinjury has both short-term and long-term negative effects on muscle healing. It appears that the temporary pain relief afforded by using ice for 20 minutes creates detrimental effects on the muscle-healing process and may produce weaker and more fibrotic muscle tissue.
A separate study also indicates that icing may produce fibrosis during the healing process (Shibaguchi et al. 2016). The researchers applied ice for 20 minutes to injured rats, then applied heat stress (107°F for 30 min) on the experimental group every other day for the next 14 days. They found that the recovery of muscle mass, protein content, and muscle fiber size toward the levels of the uninjured control group was greater in the heat-stress group and that fibrosis increased in the icing-only group. These findings indicate that using heat on acute injuries, previously anathema, may instead be a viable intervention to promote complete healing of injured skeletal muscles.
As the ice versus no-ice debate continues, practitioners are using several alternative interventions to promote more efficient recovery from acute injury. These may include treatments based on traditional Chinese medicine, or variations on the RICE protocol.
Traditional Chinese Medicine Traditional Chinese medicine (TCM) has always eschewed the use of ice for treating acute injuries. According to Bisio (2004), TCM sports medicine practitioners believe that cold and damp invades the injured area, congesting and congealing the blood and qi (also written as chi and meaning vital energy). This stagnation leads to a cascade of effects, including chronic swelling that is hard to disperse and “an arthritic type of pain that often increases with weather changes and is difficult to treat” (Bisio 2004, p. 23). TCM offers several alternative interventions to treat the swelling and inflammation of acute injuries. These include acupuncture, herbal poultices, massage with special liniments, cupping and bleeding, and oral herbal remedies.
POLICE Bleakley and colleagues (2012) have proposed POLICE(protection, optimal loading, ice, compression, and elevation). According to this editorial,
POLICE . . . is not simply a formula but a reminder to clinicians to think differently and seek out new and innovative strategies for safe and effective loading in acute soft tissue injury management. Optimal loading is an umbrella term for any mechanotherapy intervention and includes a wide range of manual techniques currently available; indeed, the term may include manual techniques such as massage refined to maximise the mechano-effect… POLICE is not just an acronym to guide management but a stimulus to a new field of research. It is important that this research includes more rigorous examination of the role of ICE in acute injury management. Currently, cold-induced analgesia and the assurance and support provided by compression and elevation are enough to retain ICE within the acronym. (2012, p. 220)
MEAT MEAT (movement, exercise, analgesia, treatment) has emerged as another alternative to RICE for treating acute soft tissue injuries, especially injuries to tendons and ligaments. The rationale for using MEAT is that early movement and appropriate exercise is better for recovery than immobilization. Buckwalter (1995) discussed the importance of controlled early resumption of activities to promote restoration of ligament and tendon function.
A systematic review of 21 studies was done in 2002 to compare the results of immobilization versus functional treatment for acute lateral ankle sprains. The reviewers concluded that
Functional treatment appears to be the favourable strategy for treating acute ankle sprains when compared with immobilisation. However, these results should be interpreted with caution, as most of the differences are not significant after exclusion of the low-quality trials. Many trials were poorly reported and there was variety amongst the functional treatments evaluated. (Kerkhoffs et al. 2002, p. 2)
As physicians, sports medicine practitioners, and researchers continue to explore these issues, it's important to remember that while each of these approaches has pros and cons, the quality of the research comparing these interventions leaves a lot to be desired. At this point in the debate, however, it appears safe to assume the cryotherapy portion of RICE is ill-advised, and movement is preferred over immobilization. The challenge for sports massage therapists is to understand, and to help their athletes understand, the rationale for not using ice, especially those athletes with a long history of using ice as their recovery modality of choice.
Understanding the science of pain
An explosion of research on pain in recent years has led to new insights into, as well as great confusion about, the origins of pain, the connections between injury and pain, and the psychological and social contributions to the perception of pain.
An explosion of research on pain in recent years has led to new insights into, as well as great confusion about, the origins of pain, the connections between injury and pain, and the psychological and social contributions to the perception of pain. This broadened knowledge of the complexity of pain has also affected the way manual therapy practitioners approach their work with clients.
By contrast, as the understanding of the mechanisms of pain perception and pain generation has progressed, many researchers and practitioners have reframed the discussion of pain in relation to injury by emphasizing that pain is a complex experience, involving many parts of the brain, and that pain perception is influenced by psychosocial factors that include previous pain experiences, thoughts and feelings about previous pain experiences, emotional states, and even personal relationships. These elements of the pain experience have been recognized for years but have been downplayed in favor of a pathomechanical model of pain that described the stimulation of pain receptors in the tissue when an injury or insult occurred there. These receptors would then stimulate the pain region of the brain, and pain would be felt. It now appears that pain receptors do not exist, but nociceptive receptors do and are stimulated by a variety of noxious stimuli, including pressure, temperature, and inflammatory markers. These receptors send signals to the brain via the spinal cord, and the brain evaluates the signal and determines whether the input is pain or not, and then outputs either the sensation of pain or something else, such as an increase in pressure or a feeling of additional warmth. What this means in practical terms for practitioners is that pain intensity does not necessarily correlate with tissue damage. Minor injuries can feel extremely painful, and severe injuries may occur with very little pain. This response is modulated by the brain and is dependent on all the biopsychosocial factors influencing the brain's final output.
In chronic pain conditions, a neural pathway can become sensitized by repeated nociceptive stimulation so that even minor noxious input can trigger output from the brain that causes the patient to feel pain. On the other hand, this does not mean that pain intensity never correlates directly with the amount of tissue damage, and it's critical for practitioners and patients to stay mindful of this fact.
Growing evidence indicates that incorporating pain neuroscience education (PNE) with manual treatment is efficacious for reducing chronic pain. The intent of PNE is to help shift the client's focus away from “my tissues are painful, so they must be injured” to realizing that the brain's perception and interpretation of stimuli emanating from the tissues may not always accurately reflect the degree of tissue damage. Encouraging a client to shift their focus away from the idea that their pain is caused by specific tissue damage has been shown to reduce chronic pain and, more importantly, to reduce pain catastrophization (magnifying the pain and feeling helpless in the presence of pain).
As practitioners and patients read and hear more about the new pain science, they may make the incorrect assumption that the oversimplified phrase “pain is in the brain” means that pain is all in your head. It's incumbent on the professionals to reassure patients that they're not making it all up (as has been the unfortunate experience of many patients). As Whitney Lowe, massage educator and author, has written,
I think one of the biggest obstacles and challenges for those who are carrying the torch of the emerging pain science specialty is to understand how to introduce these ideas to those for whom this view is new. Too often I have seen and heard pain science enthusiasts speak to others with condescension and arrogance. As a teacher I clearly recognize how that produces an immediate degree of defensiveness in a student and that is a significant obstacle to learning. (Lowe 2017, p. 1)
Because knowledge about pain perception continues to emerge and evolve, the other clear message for practitioners and patients is that our prior knowledge and experience about pain and treating patients in pain is not suddenly obsolete or ineffective. “It isn't necessary to throw out all of the valuable learning and clinical experience we have already built upon. But maybe we look at these things through a different set of glasses” (Lowe 2017, p. 1). It is incumbent on sports massage practitioners to discuss with clients the current research about pain and how those research findings will affect the treatment strategies proposed in their particular case.
What is tennis elbow?
Tennis elbow (lateral epicondylitis) is the most common overuse injury of the elbow, resulting from repetitive strain to the common extensor tendons of the wrist.
Tennis elbow (lateral epicondylitis) is the most common overuse injury of the elbow, resulting from repetitive strain to the common extensor tendons of the wrist. Although this condition is named for a sport in which it's common, it can also occur in other activities that involve repetitive stress on the wrist extensors.
Signs and Symptoms
Lateral epicondylitis (or epicondylosis if no inflammation is present) is characterized by a deep ache at the lateral epicondyle that is made worse by activity. Other symptoms may include pain at the lateral elbow, mild to moderate swelling, and limitation of wrist extension or flexion. The athlete may also experience sudden twinges of extreme pain. In well-advanced cases, sharp pain is often reported when gripping a racket or even shaking hands.
Typical History
Tennis elbow, like most overuse conditions, develops gradually over several months. It may flare up suddenly as a result of increased intensity of activity, such as competing in a tennis tournament. If the injury is not the result of a racket sport, look for repetitive motion in the client's daily activities.
Relevant Anatomy
In most cases, the primary injury is tendinopathy of the extensor carpi radialis brevis (ECRB) tendon, just distal to its attachment on the lateral epicondyle. The rest of the wrist and finger extensors may be affected by the presence of tennis elbow, either by becoming hypertonic or by becoming inhibited because of pain. See figure 7.12 for illustrations indicating the wrist and finger extensors.
Figure 7.12 Wrist and finger extensors.
Extensor Carpi Radialis Brevis
The extensor carpi radialis brevis (ECRB) originates from the common extensor tendon at the lateral epicondyle of the humerus and inserts into the dorsoradial aspect of the base of the third metacarpal bone. Actions include extension of the wrist (with the ECR longus and ulnaris) and assisting radial deviation (abduction).
Extensor Carpi Radialis Longus
The extensor carpi radialis longus (ECRL)originates on the distal third of the lateral supracondylar ridge of the humerus, lying between the origin of the brachioradialis and the lateral epicondyle and inserts into the dorsoradial aspect of the base of the second metacarpal bone. Actions include extending the wrist (along with the ECR brevis and ulnaris) and assisting radial deviation (along with the flexor carpi radialis).
Supinator
The supinator originates from the posterior ulna, the lateral epicondyle, ligaments of the elbow and radioulnar joint, and the anterior capsule of the humeroulnar joint and inserts into the anterolateral aspect of the radius, just distal to the insertion of the biceps brachii. Actions include primary supinator of the hand and forearm; with the elbow flexed, the biceps brachii assists supination and assists elbow flexion when the hand is in neutral.
The radial nerve passes through the supinator muscle, and radial nerve entrapment may create symptoms similar to tennis elbow. Trigger points in the supinator may create referred pain that mimics tennis elbow and can be deactivated as part of the overall treatment for tennis elbow. Fun fact: Because supination is a stronger action than pronation, bolts and screws are designed to tighten by supination of the right forearm (righty-tighty, lefty-loosey).
Anconeus
The anconeus originates from the posterior aspect of the lateral epicondyle of the humerus and inserts into the lateral aspect of the olecranon process and the proximal posterior ulna. Actions include assisting triceps in extension of the elbow and assisting stabilization of the elbow joint during supination and pronation. The anconeus is thought to be secondarily involved in chronic cases of tennis elbow when additional stress placed on it results in compensation or inhibition of the extensor carpi radialis brevis.
Brachioradialis
The brachioradialis originates from the upper two-thirds of the supracondylar ridge of the humerus and inserts into the lateral radius, just proximal to the styloid process. Actions include flexion at the elbow, especially when the hand is in the neutral position; it may assist resisted pronation and supination. The brachioradialis may be secondarily involved with tennis elbow because of its proximity to the extensor carpi radialis longus.
Assessment
Observation
In severe cases, visible swelling over the lateral epicondyle may be present.
ROM Assessment
Active motion at the wrist consists of flexion, extension, abduction (radial deviation), and adduction (ulnar deviation). Depending on the severity of the injury, these motions may or may not cause pain. Passive motion is generally pain free except for wrist flexion, which may stretch painful tissues on the extensor side of the forearm, especially with the elbow extended.
Resisted extension of the wrist is painful. Resisted radial deviation may also be painful.
Manual Resistive Tests
The athlete, sitting or standing, places her wrist in neutral, forearm pronated. The examiner grasps the lateral elbow with one hand, and the other hand provides resistance as the athlete attempts to extend the wrist (see figure 7.13). This isometric contraction should begin slowly and build to a strong engagement of the target muscles. With the elbow flexed, the test will engage the ECR brevis more fully; with the elbow extended, the test will focus more on the ECR longus. Pain or weakness is a positive finding. Resisted extension of the middle finger (also known as Maudsley's test) is commonly positive for pain or weakness in tennis elbow (Fairbank and Corlett 2002) (see figure 7.14). If no pain occurs, the examination widens to include the other muscles that might cause lateral epicondyle pain, such as the supinator, brachioradialis, and anconeus.
Figure 7.13 Resisted wrist extension test: with (a) elbow flexed and (b) elbow straight.
Figure 7.14 Middle-finger extension test.
Cryotherapy for acute injuries
Athletes and sports practitioners have used ice, or cryotherapy, to control the pain and inflammation of acute and chronic injuries for generations.
Athletes and sports practitioners have used ice, or cryotherapy, to control the pain and inflammation of acute and chronic injuries for generations. There is broad agreement among practitioners that inflammation is a necessary component of the healing process, but excessive or prolonged inflammation may delay or disrupt the completion of the healing process. Cryotherapy has traditionally been used to limit but not eliminate inflammation, as well as to control swelling and reduce pain.
Kenneth Knight, PhD, ATC, published Cryotherapy in Sport Injury Management in 1995, and it quickly became the go-to cryotherapy resource for practitioners. He has since written several textbooks for athletic trainers, including one with David O. Draper, Therapeutic Modalities: The Art and Science, Second Edition, published in 2013. They include an extensive and well-referenced discussion supporting the proper use of cryotherapy in the treatment of acute, subacute, and chronic injuries.
In recent years, a significant anticryotherapy movement has emerged, arguing that enough research now exists to show that cryotherapy applications delay healing of acute injuries. Gabe Mirkin, MD, is one of the experts who has published commentary against the use of ice. Mirkin takes credit for coining the acronym RICE when he and coauthor Marshall Hoffman published The Sports Medicine Book (1978). In 2015, Mirkin walked back his thinking on RICE, especially the use of ice to control inflammation.
Dr. Mirkin refers to a 2004 review of 22 studies that found almost no evidence that ice and compression promoted faster healing. The study authors concluded,
There was little evidence to suggest that the addition of ice to compression had any significant effect, but this was restricted to treatment of hospital inpatients. Few studies assessed the effectiveness of ice on closed soft tissue injury, and there was no evidence of an optimal mode or duration of treatment. (Bleakley, McDonough, and MacAuley 2004, p. 220)
It's important to note that this review did not find evidence that ice and compression delayed healing.
Two other popular proponents of the no-ice approach for acute injury are Gary Reinl, the author of Iced! The Illusionary Treatment Option (2014), and Josh Stone, ATC, CSCS, who has written extensively on his blog on the detrimental effects of cryotherapy for acute injuries (stoneathleticmedicine.com). Both of these authors provide ample research to support their conclusions.
The anti-ice proponents argue that, although ice may provide some pain relief, it delays healing by interrupting the inflammatory process, by interfering with the removal of edema from the injured area, and by preventing or slowing the release of the hormone known as insulin-like growth factor (IGF-1). IGF-1 stimulates cell growth and proliferation and inhibits cell death.
In a 2011 animal-based experiment, the effects of cryotherapy on healing after a skeletal muscle crush injury were studied (Takagi et al.). Immediately following the lab-induced injury, the experimental rats were randomly divided into no-ice and icing groups. In the latter, crushed-ice packs were applied for 20 minutes. The authors then microscopically and physiologically analyzed the healing progression of the injured muscles at 12 hours and then every day for the first 7 days and at 14 and 28 days after the injury. The results of the study showed that “icing applied soon after the injury not only considerably retarded muscle regeneration but also induced impairment of muscle regeneration along with excessive collagen deposition” (Takagi et al. 2011, p. 388). The takeaway from these results is that cryotherapy applied immediately postinjury has both short-term and long-term negative effects on muscle healing. It appears that the temporary pain relief afforded by using ice for 20 minutes creates detrimental effects on the muscle-healing process and may produce weaker and more fibrotic muscle tissue.
A separate study also indicates that icing may produce fibrosis during the healing process (Shibaguchi et al. 2016). The researchers applied ice for 20 minutes to injured rats, then applied heat stress (107°F for 30 min) on the experimental group every other day for the next 14 days. They found that the recovery of muscle mass, protein content, and muscle fiber size toward the levels of the uninjured control group was greater in the heat-stress group and that fibrosis increased in the icing-only group. These findings indicate that using heat on acute injuries, previously anathema, may instead be a viable intervention to promote complete healing of injured skeletal muscles.
As the ice versus no-ice debate continues, practitioners are using several alternative interventions to promote more efficient recovery from acute injury. These may include treatments based on traditional Chinese medicine, or variations on the RICE protocol.
Traditional Chinese Medicine Traditional Chinese medicine (TCM) has always eschewed the use of ice for treating acute injuries. According to Bisio (2004), TCM sports medicine practitioners believe that cold and damp invades the injured area, congesting and congealing the blood and qi (also written as chi and meaning vital energy). This stagnation leads to a cascade of effects, including chronic swelling that is hard to disperse and “an arthritic type of pain that often increases with weather changes and is difficult to treat” (Bisio 2004, p. 23). TCM offers several alternative interventions to treat the swelling and inflammation of acute injuries. These include acupuncture, herbal poultices, massage with special liniments, cupping and bleeding, and oral herbal remedies.
POLICE Bleakley and colleagues (2012) have proposed POLICE(protection, optimal loading, ice, compression, and elevation). According to this editorial,
POLICE . . . is not simply a formula but a reminder to clinicians to think differently and seek out new and innovative strategies for safe and effective loading in acute soft tissue injury management. Optimal loading is an umbrella term for any mechanotherapy intervention and includes a wide range of manual techniques currently available; indeed, the term may include manual techniques such as massage refined to maximise the mechano-effect… POLICE is not just an acronym to guide management but a stimulus to a new field of research. It is important that this research includes more rigorous examination of the role of ICE in acute injury management. Currently, cold-induced analgesia and the assurance and support provided by compression and elevation are enough to retain ICE within the acronym. (2012, p. 220)
MEAT MEAT (movement, exercise, analgesia, treatment) has emerged as another alternative to RICE for treating acute soft tissue injuries, especially injuries to tendons and ligaments. The rationale for using MEAT is that early movement and appropriate exercise is better for recovery than immobilization. Buckwalter (1995) discussed the importance of controlled early resumption of activities to promote restoration of ligament and tendon function.
A systematic review of 21 studies was done in 2002 to compare the results of immobilization versus functional treatment for acute lateral ankle sprains. The reviewers concluded that
Functional treatment appears to be the favourable strategy for treating acute ankle sprains when compared with immobilisation. However, these results should be interpreted with caution, as most of the differences are not significant after exclusion of the low-quality trials. Many trials were poorly reported and there was variety amongst the functional treatments evaluated. (Kerkhoffs et al. 2002, p. 2)
As physicians, sports medicine practitioners, and researchers continue to explore these issues, it's important to remember that while each of these approaches has pros and cons, the quality of the research comparing these interventions leaves a lot to be desired. At this point in the debate, however, it appears safe to assume the cryotherapy portion of RICE is ill-advised, and movement is preferred over immobilization. The challenge for sports massage therapists is to understand, and to help their athletes understand, the rationale for not using ice, especially those athletes with a long history of using ice as their recovery modality of choice.
Understanding the science of pain
An explosion of research on pain in recent years has led to new insights into, as well as great confusion about, the origins of pain, the connections between injury and pain, and the psychological and social contributions to the perception of pain.
An explosion of research on pain in recent years has led to new insights into, as well as great confusion about, the origins of pain, the connections between injury and pain, and the psychological and social contributions to the perception of pain. This broadened knowledge of the complexity of pain has also affected the way manual therapy practitioners approach their work with clients.
By contrast, as the understanding of the mechanisms of pain perception and pain generation has progressed, many researchers and practitioners have reframed the discussion of pain in relation to injury by emphasizing that pain is a complex experience, involving many parts of the brain, and that pain perception is influenced by psychosocial factors that include previous pain experiences, thoughts and feelings about previous pain experiences, emotional states, and even personal relationships. These elements of the pain experience have been recognized for years but have been downplayed in favor of a pathomechanical model of pain that described the stimulation of pain receptors in the tissue when an injury or insult occurred there. These receptors would then stimulate the pain region of the brain, and pain would be felt. It now appears that pain receptors do not exist, but nociceptive receptors do and are stimulated by a variety of noxious stimuli, including pressure, temperature, and inflammatory markers. These receptors send signals to the brain via the spinal cord, and the brain evaluates the signal and determines whether the input is pain or not, and then outputs either the sensation of pain or something else, such as an increase in pressure or a feeling of additional warmth. What this means in practical terms for practitioners is that pain intensity does not necessarily correlate with tissue damage. Minor injuries can feel extremely painful, and severe injuries may occur with very little pain. This response is modulated by the brain and is dependent on all the biopsychosocial factors influencing the brain's final output.
In chronic pain conditions, a neural pathway can become sensitized by repeated nociceptive stimulation so that even minor noxious input can trigger output from the brain that causes the patient to feel pain. On the other hand, this does not mean that pain intensity never correlates directly with the amount of tissue damage, and it's critical for practitioners and patients to stay mindful of this fact.
Growing evidence indicates that incorporating pain neuroscience education (PNE) with manual treatment is efficacious for reducing chronic pain. The intent of PNE is to help shift the client's focus away from “my tissues are painful, so they must be injured” to realizing that the brain's perception and interpretation of stimuli emanating from the tissues may not always accurately reflect the degree of tissue damage. Encouraging a client to shift their focus away from the idea that their pain is caused by specific tissue damage has been shown to reduce chronic pain and, more importantly, to reduce pain catastrophization (magnifying the pain and feeling helpless in the presence of pain).
As practitioners and patients read and hear more about the new pain science, they may make the incorrect assumption that the oversimplified phrase “pain is in the brain” means that pain is all in your head. It's incumbent on the professionals to reassure patients that they're not making it all up (as has been the unfortunate experience of many patients). As Whitney Lowe, massage educator and author, has written,
I think one of the biggest obstacles and challenges for those who are carrying the torch of the emerging pain science specialty is to understand how to introduce these ideas to those for whom this view is new. Too often I have seen and heard pain science enthusiasts speak to others with condescension and arrogance. As a teacher I clearly recognize how that produces an immediate degree of defensiveness in a student and that is a significant obstacle to learning. (Lowe 2017, p. 1)
Because knowledge about pain perception continues to emerge and evolve, the other clear message for practitioners and patients is that our prior knowledge and experience about pain and treating patients in pain is not suddenly obsolete or ineffective. “It isn't necessary to throw out all of the valuable learning and clinical experience we have already built upon. But maybe we look at these things through a different set of glasses” (Lowe 2017, p. 1). It is incumbent on sports massage practitioners to discuss with clients the current research about pain and how those research findings will affect the treatment strategies proposed in their particular case.
What is tennis elbow?
Tennis elbow (lateral epicondylitis) is the most common overuse injury of the elbow, resulting from repetitive strain to the common extensor tendons of the wrist.
Tennis elbow (lateral epicondylitis) is the most common overuse injury of the elbow, resulting from repetitive strain to the common extensor tendons of the wrist. Although this condition is named for a sport in which it's common, it can also occur in other activities that involve repetitive stress on the wrist extensors.
Signs and Symptoms
Lateral epicondylitis (or epicondylosis if no inflammation is present) is characterized by a deep ache at the lateral epicondyle that is made worse by activity. Other symptoms may include pain at the lateral elbow, mild to moderate swelling, and limitation of wrist extension or flexion. The athlete may also experience sudden twinges of extreme pain. In well-advanced cases, sharp pain is often reported when gripping a racket or even shaking hands.
Typical History
Tennis elbow, like most overuse conditions, develops gradually over several months. It may flare up suddenly as a result of increased intensity of activity, such as competing in a tennis tournament. If the injury is not the result of a racket sport, look for repetitive motion in the client's daily activities.
Relevant Anatomy
In most cases, the primary injury is tendinopathy of the extensor carpi radialis brevis (ECRB) tendon, just distal to its attachment on the lateral epicondyle. The rest of the wrist and finger extensors may be affected by the presence of tennis elbow, either by becoming hypertonic or by becoming inhibited because of pain. See figure 7.12 for illustrations indicating the wrist and finger extensors.
Figure 7.12 Wrist and finger extensors.
Extensor Carpi Radialis Brevis
The extensor carpi radialis brevis (ECRB) originates from the common extensor tendon at the lateral epicondyle of the humerus and inserts into the dorsoradial aspect of the base of the third metacarpal bone. Actions include extension of the wrist (with the ECR longus and ulnaris) and assisting radial deviation (abduction).
Extensor Carpi Radialis Longus
The extensor carpi radialis longus (ECRL)originates on the distal third of the lateral supracondylar ridge of the humerus, lying between the origin of the brachioradialis and the lateral epicondyle and inserts into the dorsoradial aspect of the base of the second metacarpal bone. Actions include extending the wrist (along with the ECR brevis and ulnaris) and assisting radial deviation (along with the flexor carpi radialis).
Supinator
The supinator originates from the posterior ulna, the lateral epicondyle, ligaments of the elbow and radioulnar joint, and the anterior capsule of the humeroulnar joint and inserts into the anterolateral aspect of the radius, just distal to the insertion of the biceps brachii. Actions include primary supinator of the hand and forearm; with the elbow flexed, the biceps brachii assists supination and assists elbow flexion when the hand is in neutral.
The radial nerve passes through the supinator muscle, and radial nerve entrapment may create symptoms similar to tennis elbow. Trigger points in the supinator may create referred pain that mimics tennis elbow and can be deactivated as part of the overall treatment for tennis elbow. Fun fact: Because supination is a stronger action than pronation, bolts and screws are designed to tighten by supination of the right forearm (righty-tighty, lefty-loosey).
Anconeus
The anconeus originates from the posterior aspect of the lateral epicondyle of the humerus and inserts into the lateral aspect of the olecranon process and the proximal posterior ulna. Actions include assisting triceps in extension of the elbow and assisting stabilization of the elbow joint during supination and pronation. The anconeus is thought to be secondarily involved in chronic cases of tennis elbow when additional stress placed on it results in compensation or inhibition of the extensor carpi radialis brevis.
Brachioradialis
The brachioradialis originates from the upper two-thirds of the supracondylar ridge of the humerus and inserts into the lateral radius, just proximal to the styloid process. Actions include flexion at the elbow, especially when the hand is in the neutral position; it may assist resisted pronation and supination. The brachioradialis may be secondarily involved with tennis elbow because of its proximity to the extensor carpi radialis longus.
Assessment
Observation
In severe cases, visible swelling over the lateral epicondyle may be present.
ROM Assessment
Active motion at the wrist consists of flexion, extension, abduction (radial deviation), and adduction (ulnar deviation). Depending on the severity of the injury, these motions may or may not cause pain. Passive motion is generally pain free except for wrist flexion, which may stretch painful tissues on the extensor side of the forearm, especially with the elbow extended.
Resisted extension of the wrist is painful. Resisted radial deviation may also be painful.
Manual Resistive Tests
The athlete, sitting or standing, places her wrist in neutral, forearm pronated. The examiner grasps the lateral elbow with one hand, and the other hand provides resistance as the athlete attempts to extend the wrist (see figure 7.13). This isometric contraction should begin slowly and build to a strong engagement of the target muscles. With the elbow flexed, the test will engage the ECR brevis more fully; with the elbow extended, the test will focus more on the ECR longus. Pain or weakness is a positive finding. Resisted extension of the middle finger (also known as Maudsley's test) is commonly positive for pain or weakness in tennis elbow (Fairbank and Corlett 2002) (see figure 7.14). If no pain occurs, the examination widens to include the other muscles that might cause lateral epicondyle pain, such as the supinator, brachioradialis, and anconeus.
Figure 7.13 Resisted wrist extension test: with (a) elbow flexed and (b) elbow straight.
Figure 7.14 Middle-finger extension test.
Cryotherapy for acute injuries
Athletes and sports practitioners have used ice, or cryotherapy, to control the pain and inflammation of acute and chronic injuries for generations.
Athletes and sports practitioners have used ice, or cryotherapy, to control the pain and inflammation of acute and chronic injuries for generations. There is broad agreement among practitioners that inflammation is a necessary component of the healing process, but excessive or prolonged inflammation may delay or disrupt the completion of the healing process. Cryotherapy has traditionally been used to limit but not eliminate inflammation, as well as to control swelling and reduce pain.
Kenneth Knight, PhD, ATC, published Cryotherapy in Sport Injury Management in 1995, and it quickly became the go-to cryotherapy resource for practitioners. He has since written several textbooks for athletic trainers, including one with David O. Draper, Therapeutic Modalities: The Art and Science, Second Edition, published in 2013. They include an extensive and well-referenced discussion supporting the proper use of cryotherapy in the treatment of acute, subacute, and chronic injuries.
In recent years, a significant anticryotherapy movement has emerged, arguing that enough research now exists to show that cryotherapy applications delay healing of acute injuries. Gabe Mirkin, MD, is one of the experts who has published commentary against the use of ice. Mirkin takes credit for coining the acronym RICE when he and coauthor Marshall Hoffman published The Sports Medicine Book (1978). In 2015, Mirkin walked back his thinking on RICE, especially the use of ice to control inflammation.
Dr. Mirkin refers to a 2004 review of 22 studies that found almost no evidence that ice and compression promoted faster healing. The study authors concluded,
There was little evidence to suggest that the addition of ice to compression had any significant effect, but this was restricted to treatment of hospital inpatients. Few studies assessed the effectiveness of ice on closed soft tissue injury, and there was no evidence of an optimal mode or duration of treatment. (Bleakley, McDonough, and MacAuley 2004, p. 220)
It's important to note that this review did not find evidence that ice and compression delayed healing.
Two other popular proponents of the no-ice approach for acute injury are Gary Reinl, the author of Iced! The Illusionary Treatment Option (2014), and Josh Stone, ATC, CSCS, who has written extensively on his blog on the detrimental effects of cryotherapy for acute injuries (stoneathleticmedicine.com). Both of these authors provide ample research to support their conclusions.
The anti-ice proponents argue that, although ice may provide some pain relief, it delays healing by interrupting the inflammatory process, by interfering with the removal of edema from the injured area, and by preventing or slowing the release of the hormone known as insulin-like growth factor (IGF-1). IGF-1 stimulates cell growth and proliferation and inhibits cell death.
In a 2011 animal-based experiment, the effects of cryotherapy on healing after a skeletal muscle crush injury were studied (Takagi et al.). Immediately following the lab-induced injury, the experimental rats were randomly divided into no-ice and icing groups. In the latter, crushed-ice packs were applied for 20 minutes. The authors then microscopically and physiologically analyzed the healing progression of the injured muscles at 12 hours and then every day for the first 7 days and at 14 and 28 days after the injury. The results of the study showed that “icing applied soon after the injury not only considerably retarded muscle regeneration but also induced impairment of muscle regeneration along with excessive collagen deposition” (Takagi et al. 2011, p. 388). The takeaway from these results is that cryotherapy applied immediately postinjury has both short-term and long-term negative effects on muscle healing. It appears that the temporary pain relief afforded by using ice for 20 minutes creates detrimental effects on the muscle-healing process and may produce weaker and more fibrotic muscle tissue.
A separate study also indicates that icing may produce fibrosis during the healing process (Shibaguchi et al. 2016). The researchers applied ice for 20 minutes to injured rats, then applied heat stress (107°F for 30 min) on the experimental group every other day for the next 14 days. They found that the recovery of muscle mass, protein content, and muscle fiber size toward the levels of the uninjured control group was greater in the heat-stress group and that fibrosis increased in the icing-only group. These findings indicate that using heat on acute injuries, previously anathema, may instead be a viable intervention to promote complete healing of injured skeletal muscles.
As the ice versus no-ice debate continues, practitioners are using several alternative interventions to promote more efficient recovery from acute injury. These may include treatments based on traditional Chinese medicine, or variations on the RICE protocol.
Traditional Chinese Medicine Traditional Chinese medicine (TCM) has always eschewed the use of ice for treating acute injuries. According to Bisio (2004), TCM sports medicine practitioners believe that cold and damp invades the injured area, congesting and congealing the blood and qi (also written as chi and meaning vital energy). This stagnation leads to a cascade of effects, including chronic swelling that is hard to disperse and “an arthritic type of pain that often increases with weather changes and is difficult to treat” (Bisio 2004, p. 23). TCM offers several alternative interventions to treat the swelling and inflammation of acute injuries. These include acupuncture, herbal poultices, massage with special liniments, cupping and bleeding, and oral herbal remedies.
POLICE Bleakley and colleagues (2012) have proposed POLICE(protection, optimal loading, ice, compression, and elevation). According to this editorial,
POLICE . . . is not simply a formula but a reminder to clinicians to think differently and seek out new and innovative strategies for safe and effective loading in acute soft tissue injury management. Optimal loading is an umbrella term for any mechanotherapy intervention and includes a wide range of manual techniques currently available; indeed, the term may include manual techniques such as massage refined to maximise the mechano-effect… POLICE is not just an acronym to guide management but a stimulus to a new field of research. It is important that this research includes more rigorous examination of the role of ICE in acute injury management. Currently, cold-induced analgesia and the assurance and support provided by compression and elevation are enough to retain ICE within the acronym. (2012, p. 220)
MEAT MEAT (movement, exercise, analgesia, treatment) has emerged as another alternative to RICE for treating acute soft tissue injuries, especially injuries to tendons and ligaments. The rationale for using MEAT is that early movement and appropriate exercise is better for recovery than immobilization. Buckwalter (1995) discussed the importance of controlled early resumption of activities to promote restoration of ligament and tendon function.
A systematic review of 21 studies was done in 2002 to compare the results of immobilization versus functional treatment for acute lateral ankle sprains. The reviewers concluded that
Functional treatment appears to be the favourable strategy for treating acute ankle sprains when compared with immobilisation. However, these results should be interpreted with caution, as most of the differences are not significant after exclusion of the low-quality trials. Many trials were poorly reported and there was variety amongst the functional treatments evaluated. (Kerkhoffs et al. 2002, p. 2)
As physicians, sports medicine practitioners, and researchers continue to explore these issues, it's important to remember that while each of these approaches has pros and cons, the quality of the research comparing these interventions leaves a lot to be desired. At this point in the debate, however, it appears safe to assume the cryotherapy portion of RICE is ill-advised, and movement is preferred over immobilization. The challenge for sports massage therapists is to understand, and to help their athletes understand, the rationale for not using ice, especially those athletes with a long history of using ice as their recovery modality of choice.
Understanding the science of pain
An explosion of research on pain in recent years has led to new insights into, as well as great confusion about, the origins of pain, the connections between injury and pain, and the psychological and social contributions to the perception of pain.
An explosion of research on pain in recent years has led to new insights into, as well as great confusion about, the origins of pain, the connections between injury and pain, and the psychological and social contributions to the perception of pain. This broadened knowledge of the complexity of pain has also affected the way manual therapy practitioners approach their work with clients.
By contrast, as the understanding of the mechanisms of pain perception and pain generation has progressed, many researchers and practitioners have reframed the discussion of pain in relation to injury by emphasizing that pain is a complex experience, involving many parts of the brain, and that pain perception is influenced by psychosocial factors that include previous pain experiences, thoughts and feelings about previous pain experiences, emotional states, and even personal relationships. These elements of the pain experience have been recognized for years but have been downplayed in favor of a pathomechanical model of pain that described the stimulation of pain receptors in the tissue when an injury or insult occurred there. These receptors would then stimulate the pain region of the brain, and pain would be felt. It now appears that pain receptors do not exist, but nociceptive receptors do and are stimulated by a variety of noxious stimuli, including pressure, temperature, and inflammatory markers. These receptors send signals to the brain via the spinal cord, and the brain evaluates the signal and determines whether the input is pain or not, and then outputs either the sensation of pain or something else, such as an increase in pressure or a feeling of additional warmth. What this means in practical terms for practitioners is that pain intensity does not necessarily correlate with tissue damage. Minor injuries can feel extremely painful, and severe injuries may occur with very little pain. This response is modulated by the brain and is dependent on all the biopsychosocial factors influencing the brain's final output.
In chronic pain conditions, a neural pathway can become sensitized by repeated nociceptive stimulation so that even minor noxious input can trigger output from the brain that causes the patient to feel pain. On the other hand, this does not mean that pain intensity never correlates directly with the amount of tissue damage, and it's critical for practitioners and patients to stay mindful of this fact.
Growing evidence indicates that incorporating pain neuroscience education (PNE) with manual treatment is efficacious for reducing chronic pain. The intent of PNE is to help shift the client's focus away from “my tissues are painful, so they must be injured” to realizing that the brain's perception and interpretation of stimuli emanating from the tissues may not always accurately reflect the degree of tissue damage. Encouraging a client to shift their focus away from the idea that their pain is caused by specific tissue damage has been shown to reduce chronic pain and, more importantly, to reduce pain catastrophization (magnifying the pain and feeling helpless in the presence of pain).
As practitioners and patients read and hear more about the new pain science, they may make the incorrect assumption that the oversimplified phrase “pain is in the brain” means that pain is all in your head. It's incumbent on the professionals to reassure patients that they're not making it all up (as has been the unfortunate experience of many patients). As Whitney Lowe, massage educator and author, has written,
I think one of the biggest obstacles and challenges for those who are carrying the torch of the emerging pain science specialty is to understand how to introduce these ideas to those for whom this view is new. Too often I have seen and heard pain science enthusiasts speak to others with condescension and arrogance. As a teacher I clearly recognize how that produces an immediate degree of defensiveness in a student and that is a significant obstacle to learning. (Lowe 2017, p. 1)
Because knowledge about pain perception continues to emerge and evolve, the other clear message for practitioners and patients is that our prior knowledge and experience about pain and treating patients in pain is not suddenly obsolete or ineffective. “It isn't necessary to throw out all of the valuable learning and clinical experience we have already built upon. But maybe we look at these things through a different set of glasses” (Lowe 2017, p. 1). It is incumbent on sports massage practitioners to discuss with clients the current research about pain and how those research findings will affect the treatment strategies proposed in their particular case.
What is tennis elbow?
Tennis elbow (lateral epicondylitis) is the most common overuse injury of the elbow, resulting from repetitive strain to the common extensor tendons of the wrist.
Tennis elbow (lateral epicondylitis) is the most common overuse injury of the elbow, resulting from repetitive strain to the common extensor tendons of the wrist. Although this condition is named for a sport in which it's common, it can also occur in other activities that involve repetitive stress on the wrist extensors.
Signs and Symptoms
Lateral epicondylitis (or epicondylosis if no inflammation is present) is characterized by a deep ache at the lateral epicondyle that is made worse by activity. Other symptoms may include pain at the lateral elbow, mild to moderate swelling, and limitation of wrist extension or flexion. The athlete may also experience sudden twinges of extreme pain. In well-advanced cases, sharp pain is often reported when gripping a racket or even shaking hands.
Typical History
Tennis elbow, like most overuse conditions, develops gradually over several months. It may flare up suddenly as a result of increased intensity of activity, such as competing in a tennis tournament. If the injury is not the result of a racket sport, look for repetitive motion in the client's daily activities.
Relevant Anatomy
In most cases, the primary injury is tendinopathy of the extensor carpi radialis brevis (ECRB) tendon, just distal to its attachment on the lateral epicondyle. The rest of the wrist and finger extensors may be affected by the presence of tennis elbow, either by becoming hypertonic or by becoming inhibited because of pain. See figure 7.12 for illustrations indicating the wrist and finger extensors.
Figure 7.12 Wrist and finger extensors.
Extensor Carpi Radialis Brevis
The extensor carpi radialis brevis (ECRB) originates from the common extensor tendon at the lateral epicondyle of the humerus and inserts into the dorsoradial aspect of the base of the third metacarpal bone. Actions include extension of the wrist (with the ECR longus and ulnaris) and assisting radial deviation (abduction).
Extensor Carpi Radialis Longus
The extensor carpi radialis longus (ECRL)originates on the distal third of the lateral supracondylar ridge of the humerus, lying between the origin of the brachioradialis and the lateral epicondyle and inserts into the dorsoradial aspect of the base of the second metacarpal bone. Actions include extending the wrist (along with the ECR brevis and ulnaris) and assisting radial deviation (along with the flexor carpi radialis).
Supinator
The supinator originates from the posterior ulna, the lateral epicondyle, ligaments of the elbow and radioulnar joint, and the anterior capsule of the humeroulnar joint and inserts into the anterolateral aspect of the radius, just distal to the insertion of the biceps brachii. Actions include primary supinator of the hand and forearm; with the elbow flexed, the biceps brachii assists supination and assists elbow flexion when the hand is in neutral.
The radial nerve passes through the supinator muscle, and radial nerve entrapment may create symptoms similar to tennis elbow. Trigger points in the supinator may create referred pain that mimics tennis elbow and can be deactivated as part of the overall treatment for tennis elbow. Fun fact: Because supination is a stronger action than pronation, bolts and screws are designed to tighten by supination of the right forearm (righty-tighty, lefty-loosey).
Anconeus
The anconeus originates from the posterior aspect of the lateral epicondyle of the humerus and inserts into the lateral aspect of the olecranon process and the proximal posterior ulna. Actions include assisting triceps in extension of the elbow and assisting stabilization of the elbow joint during supination and pronation. The anconeus is thought to be secondarily involved in chronic cases of tennis elbow when additional stress placed on it results in compensation or inhibition of the extensor carpi radialis brevis.
Brachioradialis
The brachioradialis originates from the upper two-thirds of the supracondylar ridge of the humerus and inserts into the lateral radius, just proximal to the styloid process. Actions include flexion at the elbow, especially when the hand is in the neutral position; it may assist resisted pronation and supination. The brachioradialis may be secondarily involved with tennis elbow because of its proximity to the extensor carpi radialis longus.
Assessment
Observation
In severe cases, visible swelling over the lateral epicondyle may be present.
ROM Assessment
Active motion at the wrist consists of flexion, extension, abduction (radial deviation), and adduction (ulnar deviation). Depending on the severity of the injury, these motions may or may not cause pain. Passive motion is generally pain free except for wrist flexion, which may stretch painful tissues on the extensor side of the forearm, especially with the elbow extended.
Resisted extension of the wrist is painful. Resisted radial deviation may also be painful.
Manual Resistive Tests
The athlete, sitting or standing, places her wrist in neutral, forearm pronated. The examiner grasps the lateral elbow with one hand, and the other hand provides resistance as the athlete attempts to extend the wrist (see figure 7.13). This isometric contraction should begin slowly and build to a strong engagement of the target muscles. With the elbow flexed, the test will engage the ECR brevis more fully; with the elbow extended, the test will focus more on the ECR longus. Pain or weakness is a positive finding. Resisted extension of the middle finger (also known as Maudsley's test) is commonly positive for pain or weakness in tennis elbow (Fairbank and Corlett 2002) (see figure 7.14). If no pain occurs, the examination widens to include the other muscles that might cause lateral epicondyle pain, such as the supinator, brachioradialis, and anconeus.
Figure 7.13 Resisted wrist extension test: with (a) elbow flexed and (b) elbow straight.
Figure 7.14 Middle-finger extension test.
Cryotherapy for acute injuries
Athletes and sports practitioners have used ice, or cryotherapy, to control the pain and inflammation of acute and chronic injuries for generations.
Athletes and sports practitioners have used ice, or cryotherapy, to control the pain and inflammation of acute and chronic injuries for generations. There is broad agreement among practitioners that inflammation is a necessary component of the healing process, but excessive or prolonged inflammation may delay or disrupt the completion of the healing process. Cryotherapy has traditionally been used to limit but not eliminate inflammation, as well as to control swelling and reduce pain.
Kenneth Knight, PhD, ATC, published Cryotherapy in Sport Injury Management in 1995, and it quickly became the go-to cryotherapy resource for practitioners. He has since written several textbooks for athletic trainers, including one with David O. Draper, Therapeutic Modalities: The Art and Science, Second Edition, published in 2013. They include an extensive and well-referenced discussion supporting the proper use of cryotherapy in the treatment of acute, subacute, and chronic injuries.
In recent years, a significant anticryotherapy movement has emerged, arguing that enough research now exists to show that cryotherapy applications delay healing of acute injuries. Gabe Mirkin, MD, is one of the experts who has published commentary against the use of ice. Mirkin takes credit for coining the acronym RICE when he and coauthor Marshall Hoffman published The Sports Medicine Book (1978). In 2015, Mirkin walked back his thinking on RICE, especially the use of ice to control inflammation.
Dr. Mirkin refers to a 2004 review of 22 studies that found almost no evidence that ice and compression promoted faster healing. The study authors concluded,
There was little evidence to suggest that the addition of ice to compression had any significant effect, but this was restricted to treatment of hospital inpatients. Few studies assessed the effectiveness of ice on closed soft tissue injury, and there was no evidence of an optimal mode or duration of treatment. (Bleakley, McDonough, and MacAuley 2004, p. 220)
It's important to note that this review did not find evidence that ice and compression delayed healing.
Two other popular proponents of the no-ice approach for acute injury are Gary Reinl, the author of Iced! The Illusionary Treatment Option (2014), and Josh Stone, ATC, CSCS, who has written extensively on his blog on the detrimental effects of cryotherapy for acute injuries (stoneathleticmedicine.com). Both of these authors provide ample research to support their conclusions.
The anti-ice proponents argue that, although ice may provide some pain relief, it delays healing by interrupting the inflammatory process, by interfering with the removal of edema from the injured area, and by preventing or slowing the release of the hormone known as insulin-like growth factor (IGF-1). IGF-1 stimulates cell growth and proliferation and inhibits cell death.
In a 2011 animal-based experiment, the effects of cryotherapy on healing after a skeletal muscle crush injury were studied (Takagi et al.). Immediately following the lab-induced injury, the experimental rats were randomly divided into no-ice and icing groups. In the latter, crushed-ice packs were applied for 20 minutes. The authors then microscopically and physiologically analyzed the healing progression of the injured muscles at 12 hours and then every day for the first 7 days and at 14 and 28 days after the injury. The results of the study showed that “icing applied soon after the injury not only considerably retarded muscle regeneration but also induced impairment of muscle regeneration along with excessive collagen deposition” (Takagi et al. 2011, p. 388). The takeaway from these results is that cryotherapy applied immediately postinjury has both short-term and long-term negative effects on muscle healing. It appears that the temporary pain relief afforded by using ice for 20 minutes creates detrimental effects on the muscle-healing process and may produce weaker and more fibrotic muscle tissue.
A separate study also indicates that icing may produce fibrosis during the healing process (Shibaguchi et al. 2016). The researchers applied ice for 20 minutes to injured rats, then applied heat stress (107°F for 30 min) on the experimental group every other day for the next 14 days. They found that the recovery of muscle mass, protein content, and muscle fiber size toward the levels of the uninjured control group was greater in the heat-stress group and that fibrosis increased in the icing-only group. These findings indicate that using heat on acute injuries, previously anathema, may instead be a viable intervention to promote complete healing of injured skeletal muscles.
As the ice versus no-ice debate continues, practitioners are using several alternative interventions to promote more efficient recovery from acute injury. These may include treatments based on traditional Chinese medicine, or variations on the RICE protocol.
Traditional Chinese Medicine Traditional Chinese medicine (TCM) has always eschewed the use of ice for treating acute injuries. According to Bisio (2004), TCM sports medicine practitioners believe that cold and damp invades the injured area, congesting and congealing the blood and qi (also written as chi and meaning vital energy). This stagnation leads to a cascade of effects, including chronic swelling that is hard to disperse and “an arthritic type of pain that often increases with weather changes and is difficult to treat” (Bisio 2004, p. 23). TCM offers several alternative interventions to treat the swelling and inflammation of acute injuries. These include acupuncture, herbal poultices, massage with special liniments, cupping and bleeding, and oral herbal remedies.
POLICE Bleakley and colleagues (2012) have proposed POLICE(protection, optimal loading, ice, compression, and elevation). According to this editorial,
POLICE . . . is not simply a formula but a reminder to clinicians to think differently and seek out new and innovative strategies for safe and effective loading in acute soft tissue injury management. Optimal loading is an umbrella term for any mechanotherapy intervention and includes a wide range of manual techniques currently available; indeed, the term may include manual techniques such as massage refined to maximise the mechano-effect… POLICE is not just an acronym to guide management but a stimulus to a new field of research. It is important that this research includes more rigorous examination of the role of ICE in acute injury management. Currently, cold-induced analgesia and the assurance and support provided by compression and elevation are enough to retain ICE within the acronym. (2012, p. 220)
MEAT MEAT (movement, exercise, analgesia, treatment) has emerged as another alternative to RICE for treating acute soft tissue injuries, especially injuries to tendons and ligaments. The rationale for using MEAT is that early movement and appropriate exercise is better for recovery than immobilization. Buckwalter (1995) discussed the importance of controlled early resumption of activities to promote restoration of ligament and tendon function.
A systematic review of 21 studies was done in 2002 to compare the results of immobilization versus functional treatment for acute lateral ankle sprains. The reviewers concluded that
Functional treatment appears to be the favourable strategy for treating acute ankle sprains when compared with immobilisation. However, these results should be interpreted with caution, as most of the differences are not significant after exclusion of the low-quality trials. Many trials were poorly reported and there was variety amongst the functional treatments evaluated. (Kerkhoffs et al. 2002, p. 2)
As physicians, sports medicine practitioners, and researchers continue to explore these issues, it's important to remember that while each of these approaches has pros and cons, the quality of the research comparing these interventions leaves a lot to be desired. At this point in the debate, however, it appears safe to assume the cryotherapy portion of RICE is ill-advised, and movement is preferred over immobilization. The challenge for sports massage therapists is to understand, and to help their athletes understand, the rationale for not using ice, especially those athletes with a long history of using ice as their recovery modality of choice.
Understanding the science of pain
An explosion of research on pain in recent years has led to new insights into, as well as great confusion about, the origins of pain, the connections between injury and pain, and the psychological and social contributions to the perception of pain.
An explosion of research on pain in recent years has led to new insights into, as well as great confusion about, the origins of pain, the connections between injury and pain, and the psychological and social contributions to the perception of pain. This broadened knowledge of the complexity of pain has also affected the way manual therapy practitioners approach their work with clients.
By contrast, as the understanding of the mechanisms of pain perception and pain generation has progressed, many researchers and practitioners have reframed the discussion of pain in relation to injury by emphasizing that pain is a complex experience, involving many parts of the brain, and that pain perception is influenced by psychosocial factors that include previous pain experiences, thoughts and feelings about previous pain experiences, emotional states, and even personal relationships. These elements of the pain experience have been recognized for years but have been downplayed in favor of a pathomechanical model of pain that described the stimulation of pain receptors in the tissue when an injury or insult occurred there. These receptors would then stimulate the pain region of the brain, and pain would be felt. It now appears that pain receptors do not exist, but nociceptive receptors do and are stimulated by a variety of noxious stimuli, including pressure, temperature, and inflammatory markers. These receptors send signals to the brain via the spinal cord, and the brain evaluates the signal and determines whether the input is pain or not, and then outputs either the sensation of pain or something else, such as an increase in pressure or a feeling of additional warmth. What this means in practical terms for practitioners is that pain intensity does not necessarily correlate with tissue damage. Minor injuries can feel extremely painful, and severe injuries may occur with very little pain. This response is modulated by the brain and is dependent on all the biopsychosocial factors influencing the brain's final output.
In chronic pain conditions, a neural pathway can become sensitized by repeated nociceptive stimulation so that even minor noxious input can trigger output from the brain that causes the patient to feel pain. On the other hand, this does not mean that pain intensity never correlates directly with the amount of tissue damage, and it's critical for practitioners and patients to stay mindful of this fact.
Growing evidence indicates that incorporating pain neuroscience education (PNE) with manual treatment is efficacious for reducing chronic pain. The intent of PNE is to help shift the client's focus away from “my tissues are painful, so they must be injured” to realizing that the brain's perception and interpretation of stimuli emanating from the tissues may not always accurately reflect the degree of tissue damage. Encouraging a client to shift their focus away from the idea that their pain is caused by specific tissue damage has been shown to reduce chronic pain and, more importantly, to reduce pain catastrophization (magnifying the pain and feeling helpless in the presence of pain).
As practitioners and patients read and hear more about the new pain science, they may make the incorrect assumption that the oversimplified phrase “pain is in the brain” means that pain is all in your head. It's incumbent on the professionals to reassure patients that they're not making it all up (as has been the unfortunate experience of many patients). As Whitney Lowe, massage educator and author, has written,
I think one of the biggest obstacles and challenges for those who are carrying the torch of the emerging pain science specialty is to understand how to introduce these ideas to those for whom this view is new. Too often I have seen and heard pain science enthusiasts speak to others with condescension and arrogance. As a teacher I clearly recognize how that produces an immediate degree of defensiveness in a student and that is a significant obstacle to learning. (Lowe 2017, p. 1)
Because knowledge about pain perception continues to emerge and evolve, the other clear message for practitioners and patients is that our prior knowledge and experience about pain and treating patients in pain is not suddenly obsolete or ineffective. “It isn't necessary to throw out all of the valuable learning and clinical experience we have already built upon. But maybe we look at these things through a different set of glasses” (Lowe 2017, p. 1). It is incumbent on sports massage practitioners to discuss with clients the current research about pain and how those research findings will affect the treatment strategies proposed in their particular case.
What is tennis elbow?
Tennis elbow (lateral epicondylitis) is the most common overuse injury of the elbow, resulting from repetitive strain to the common extensor tendons of the wrist.
Tennis elbow (lateral epicondylitis) is the most common overuse injury of the elbow, resulting from repetitive strain to the common extensor tendons of the wrist. Although this condition is named for a sport in which it's common, it can also occur in other activities that involve repetitive stress on the wrist extensors.
Signs and Symptoms
Lateral epicondylitis (or epicondylosis if no inflammation is present) is characterized by a deep ache at the lateral epicondyle that is made worse by activity. Other symptoms may include pain at the lateral elbow, mild to moderate swelling, and limitation of wrist extension or flexion. The athlete may also experience sudden twinges of extreme pain. In well-advanced cases, sharp pain is often reported when gripping a racket or even shaking hands.
Typical History
Tennis elbow, like most overuse conditions, develops gradually over several months. It may flare up suddenly as a result of increased intensity of activity, such as competing in a tennis tournament. If the injury is not the result of a racket sport, look for repetitive motion in the client's daily activities.
Relevant Anatomy
In most cases, the primary injury is tendinopathy of the extensor carpi radialis brevis (ECRB) tendon, just distal to its attachment on the lateral epicondyle. The rest of the wrist and finger extensors may be affected by the presence of tennis elbow, either by becoming hypertonic or by becoming inhibited because of pain. See figure 7.12 for illustrations indicating the wrist and finger extensors.
Figure 7.12 Wrist and finger extensors.
Extensor Carpi Radialis Brevis
The extensor carpi radialis brevis (ECRB) originates from the common extensor tendon at the lateral epicondyle of the humerus and inserts into the dorsoradial aspect of the base of the third metacarpal bone. Actions include extension of the wrist (with the ECR longus and ulnaris) and assisting radial deviation (abduction).
Extensor Carpi Radialis Longus
The extensor carpi radialis longus (ECRL)originates on the distal third of the lateral supracondylar ridge of the humerus, lying between the origin of the brachioradialis and the lateral epicondyle and inserts into the dorsoradial aspect of the base of the second metacarpal bone. Actions include extending the wrist (along with the ECR brevis and ulnaris) and assisting radial deviation (along with the flexor carpi radialis).
Supinator
The supinator originates from the posterior ulna, the lateral epicondyle, ligaments of the elbow and radioulnar joint, and the anterior capsule of the humeroulnar joint and inserts into the anterolateral aspect of the radius, just distal to the insertion of the biceps brachii. Actions include primary supinator of the hand and forearm; with the elbow flexed, the biceps brachii assists supination and assists elbow flexion when the hand is in neutral.
The radial nerve passes through the supinator muscle, and radial nerve entrapment may create symptoms similar to tennis elbow. Trigger points in the supinator may create referred pain that mimics tennis elbow and can be deactivated as part of the overall treatment for tennis elbow. Fun fact: Because supination is a stronger action than pronation, bolts and screws are designed to tighten by supination of the right forearm (righty-tighty, lefty-loosey).
Anconeus
The anconeus originates from the posterior aspect of the lateral epicondyle of the humerus and inserts into the lateral aspect of the olecranon process and the proximal posterior ulna. Actions include assisting triceps in extension of the elbow and assisting stabilization of the elbow joint during supination and pronation. The anconeus is thought to be secondarily involved in chronic cases of tennis elbow when additional stress placed on it results in compensation or inhibition of the extensor carpi radialis brevis.
Brachioradialis
The brachioradialis originates from the upper two-thirds of the supracondylar ridge of the humerus and inserts into the lateral radius, just proximal to the styloid process. Actions include flexion at the elbow, especially when the hand is in the neutral position; it may assist resisted pronation and supination. The brachioradialis may be secondarily involved with tennis elbow because of its proximity to the extensor carpi radialis longus.
Assessment
Observation
In severe cases, visible swelling over the lateral epicondyle may be present.
ROM Assessment
Active motion at the wrist consists of flexion, extension, abduction (radial deviation), and adduction (ulnar deviation). Depending on the severity of the injury, these motions may or may not cause pain. Passive motion is generally pain free except for wrist flexion, which may stretch painful tissues on the extensor side of the forearm, especially with the elbow extended.
Resisted extension of the wrist is painful. Resisted radial deviation may also be painful.
Manual Resistive Tests
The athlete, sitting or standing, places her wrist in neutral, forearm pronated. The examiner grasps the lateral elbow with one hand, and the other hand provides resistance as the athlete attempts to extend the wrist (see figure 7.13). This isometric contraction should begin slowly and build to a strong engagement of the target muscles. With the elbow flexed, the test will engage the ECR brevis more fully; with the elbow extended, the test will focus more on the ECR longus. Pain or weakness is a positive finding. Resisted extension of the middle finger (also known as Maudsley's test) is commonly positive for pain or weakness in tennis elbow (Fairbank and Corlett 2002) (see figure 7.14). If no pain occurs, the examination widens to include the other muscles that might cause lateral epicondyle pain, such as the supinator, brachioradialis, and anconeus.
Figure 7.13 Resisted wrist extension test: with (a) elbow flexed and (b) elbow straight.
Figure 7.14 Middle-finger extension test.
Cryotherapy for acute injuries
Athletes and sports practitioners have used ice, or cryotherapy, to control the pain and inflammation of acute and chronic injuries for generations.
Athletes and sports practitioners have used ice, or cryotherapy, to control the pain and inflammation of acute and chronic injuries for generations. There is broad agreement among practitioners that inflammation is a necessary component of the healing process, but excessive or prolonged inflammation may delay or disrupt the completion of the healing process. Cryotherapy has traditionally been used to limit but not eliminate inflammation, as well as to control swelling and reduce pain.
Kenneth Knight, PhD, ATC, published Cryotherapy in Sport Injury Management in 1995, and it quickly became the go-to cryotherapy resource for practitioners. He has since written several textbooks for athletic trainers, including one with David O. Draper, Therapeutic Modalities: The Art and Science, Second Edition, published in 2013. They include an extensive and well-referenced discussion supporting the proper use of cryotherapy in the treatment of acute, subacute, and chronic injuries.
In recent years, a significant anticryotherapy movement has emerged, arguing that enough research now exists to show that cryotherapy applications delay healing of acute injuries. Gabe Mirkin, MD, is one of the experts who has published commentary against the use of ice. Mirkin takes credit for coining the acronym RICE when he and coauthor Marshall Hoffman published The Sports Medicine Book (1978). In 2015, Mirkin walked back his thinking on RICE, especially the use of ice to control inflammation.
Dr. Mirkin refers to a 2004 review of 22 studies that found almost no evidence that ice and compression promoted faster healing. The study authors concluded,
There was little evidence to suggest that the addition of ice to compression had any significant effect, but this was restricted to treatment of hospital inpatients. Few studies assessed the effectiveness of ice on closed soft tissue injury, and there was no evidence of an optimal mode or duration of treatment. (Bleakley, McDonough, and MacAuley 2004, p. 220)
It's important to note that this review did not find evidence that ice and compression delayed healing.
Two other popular proponents of the no-ice approach for acute injury are Gary Reinl, the author of Iced! The Illusionary Treatment Option (2014), and Josh Stone, ATC, CSCS, who has written extensively on his blog on the detrimental effects of cryotherapy for acute injuries (stoneathleticmedicine.com). Both of these authors provide ample research to support their conclusions.
The anti-ice proponents argue that, although ice may provide some pain relief, it delays healing by interrupting the inflammatory process, by interfering with the removal of edema from the injured area, and by preventing or slowing the release of the hormone known as insulin-like growth factor (IGF-1). IGF-1 stimulates cell growth and proliferation and inhibits cell death.
In a 2011 animal-based experiment, the effects of cryotherapy on healing after a skeletal muscle crush injury were studied (Takagi et al.). Immediately following the lab-induced injury, the experimental rats were randomly divided into no-ice and icing groups. In the latter, crushed-ice packs were applied for 20 minutes. The authors then microscopically and physiologically analyzed the healing progression of the injured muscles at 12 hours and then every day for the first 7 days and at 14 and 28 days after the injury. The results of the study showed that “icing applied soon after the injury not only considerably retarded muscle regeneration but also induced impairment of muscle regeneration along with excessive collagen deposition” (Takagi et al. 2011, p. 388). The takeaway from these results is that cryotherapy applied immediately postinjury has both short-term and long-term negative effects on muscle healing. It appears that the temporary pain relief afforded by using ice for 20 minutes creates detrimental effects on the muscle-healing process and may produce weaker and more fibrotic muscle tissue.
A separate study also indicates that icing may produce fibrosis during the healing process (Shibaguchi et al. 2016). The researchers applied ice for 20 minutes to injured rats, then applied heat stress (107°F for 30 min) on the experimental group every other day for the next 14 days. They found that the recovery of muscle mass, protein content, and muscle fiber size toward the levels of the uninjured control group was greater in the heat-stress group and that fibrosis increased in the icing-only group. These findings indicate that using heat on acute injuries, previously anathema, may instead be a viable intervention to promote complete healing of injured skeletal muscles.
As the ice versus no-ice debate continues, practitioners are using several alternative interventions to promote more efficient recovery from acute injury. These may include treatments based on traditional Chinese medicine, or variations on the RICE protocol.
Traditional Chinese Medicine Traditional Chinese medicine (TCM) has always eschewed the use of ice for treating acute injuries. According to Bisio (2004), TCM sports medicine practitioners believe that cold and damp invades the injured area, congesting and congealing the blood and qi (also written as chi and meaning vital energy). This stagnation leads to a cascade of effects, including chronic swelling that is hard to disperse and “an arthritic type of pain that often increases with weather changes and is difficult to treat” (Bisio 2004, p. 23). TCM offers several alternative interventions to treat the swelling and inflammation of acute injuries. These include acupuncture, herbal poultices, massage with special liniments, cupping and bleeding, and oral herbal remedies.
POLICE Bleakley and colleagues (2012) have proposed POLICE(protection, optimal loading, ice, compression, and elevation). According to this editorial,
POLICE . . . is not simply a formula but a reminder to clinicians to think differently and seek out new and innovative strategies for safe and effective loading in acute soft tissue injury management. Optimal loading is an umbrella term for any mechanotherapy intervention and includes a wide range of manual techniques currently available; indeed, the term may include manual techniques such as massage refined to maximise the mechano-effect… POLICE is not just an acronym to guide management but a stimulus to a new field of research. It is important that this research includes more rigorous examination of the role of ICE in acute injury management. Currently, cold-induced analgesia and the assurance and support provided by compression and elevation are enough to retain ICE within the acronym. (2012, p. 220)
MEAT MEAT (movement, exercise, analgesia, treatment) has emerged as another alternative to RICE for treating acute soft tissue injuries, especially injuries to tendons and ligaments. The rationale for using MEAT is that early movement and appropriate exercise is better for recovery than immobilization. Buckwalter (1995) discussed the importance of controlled early resumption of activities to promote restoration of ligament and tendon function.
A systematic review of 21 studies was done in 2002 to compare the results of immobilization versus functional treatment for acute lateral ankle sprains. The reviewers concluded that
Functional treatment appears to be the favourable strategy for treating acute ankle sprains when compared with immobilisation. However, these results should be interpreted with caution, as most of the differences are not significant after exclusion of the low-quality trials. Many trials were poorly reported and there was variety amongst the functional treatments evaluated. (Kerkhoffs et al. 2002, p. 2)
As physicians, sports medicine practitioners, and researchers continue to explore these issues, it's important to remember that while each of these approaches has pros and cons, the quality of the research comparing these interventions leaves a lot to be desired. At this point in the debate, however, it appears safe to assume the cryotherapy portion of RICE is ill-advised, and movement is preferred over immobilization. The challenge for sports massage therapists is to understand, and to help their athletes understand, the rationale for not using ice, especially those athletes with a long history of using ice as their recovery modality of choice.
Understanding the science of pain
An explosion of research on pain in recent years has led to new insights into, as well as great confusion about, the origins of pain, the connections between injury and pain, and the psychological and social contributions to the perception of pain.
An explosion of research on pain in recent years has led to new insights into, as well as great confusion about, the origins of pain, the connections between injury and pain, and the psychological and social contributions to the perception of pain. This broadened knowledge of the complexity of pain has also affected the way manual therapy practitioners approach their work with clients.
By contrast, as the understanding of the mechanisms of pain perception and pain generation has progressed, many researchers and practitioners have reframed the discussion of pain in relation to injury by emphasizing that pain is a complex experience, involving many parts of the brain, and that pain perception is influenced by psychosocial factors that include previous pain experiences, thoughts and feelings about previous pain experiences, emotional states, and even personal relationships. These elements of the pain experience have been recognized for years but have been downplayed in favor of a pathomechanical model of pain that described the stimulation of pain receptors in the tissue when an injury or insult occurred there. These receptors would then stimulate the pain region of the brain, and pain would be felt. It now appears that pain receptors do not exist, but nociceptive receptors do and are stimulated by a variety of noxious stimuli, including pressure, temperature, and inflammatory markers. These receptors send signals to the brain via the spinal cord, and the brain evaluates the signal and determines whether the input is pain or not, and then outputs either the sensation of pain or something else, such as an increase in pressure or a feeling of additional warmth. What this means in practical terms for practitioners is that pain intensity does not necessarily correlate with tissue damage. Minor injuries can feel extremely painful, and severe injuries may occur with very little pain. This response is modulated by the brain and is dependent on all the biopsychosocial factors influencing the brain's final output.
In chronic pain conditions, a neural pathway can become sensitized by repeated nociceptive stimulation so that even minor noxious input can trigger output from the brain that causes the patient to feel pain. On the other hand, this does not mean that pain intensity never correlates directly with the amount of tissue damage, and it's critical for practitioners and patients to stay mindful of this fact.
Growing evidence indicates that incorporating pain neuroscience education (PNE) with manual treatment is efficacious for reducing chronic pain. The intent of PNE is to help shift the client's focus away from “my tissues are painful, so they must be injured” to realizing that the brain's perception and interpretation of stimuli emanating from the tissues may not always accurately reflect the degree of tissue damage. Encouraging a client to shift their focus away from the idea that their pain is caused by specific tissue damage has been shown to reduce chronic pain and, more importantly, to reduce pain catastrophization (magnifying the pain and feeling helpless in the presence of pain).
As practitioners and patients read and hear more about the new pain science, they may make the incorrect assumption that the oversimplified phrase “pain is in the brain” means that pain is all in your head. It's incumbent on the professionals to reassure patients that they're not making it all up (as has been the unfortunate experience of many patients). As Whitney Lowe, massage educator and author, has written,
I think one of the biggest obstacles and challenges for those who are carrying the torch of the emerging pain science specialty is to understand how to introduce these ideas to those for whom this view is new. Too often I have seen and heard pain science enthusiasts speak to others with condescension and arrogance. As a teacher I clearly recognize how that produces an immediate degree of defensiveness in a student and that is a significant obstacle to learning. (Lowe 2017, p. 1)
Because knowledge about pain perception continues to emerge and evolve, the other clear message for practitioners and patients is that our prior knowledge and experience about pain and treating patients in pain is not suddenly obsolete or ineffective. “It isn't necessary to throw out all of the valuable learning and clinical experience we have already built upon. But maybe we look at these things through a different set of glasses” (Lowe 2017, p. 1). It is incumbent on sports massage practitioners to discuss with clients the current research about pain and how those research findings will affect the treatment strategies proposed in their particular case.
What is tennis elbow?
Tennis elbow (lateral epicondylitis) is the most common overuse injury of the elbow, resulting from repetitive strain to the common extensor tendons of the wrist.
Tennis elbow (lateral epicondylitis) is the most common overuse injury of the elbow, resulting from repetitive strain to the common extensor tendons of the wrist. Although this condition is named for a sport in which it's common, it can also occur in other activities that involve repetitive stress on the wrist extensors.
Signs and Symptoms
Lateral epicondylitis (or epicondylosis if no inflammation is present) is characterized by a deep ache at the lateral epicondyle that is made worse by activity. Other symptoms may include pain at the lateral elbow, mild to moderate swelling, and limitation of wrist extension or flexion. The athlete may also experience sudden twinges of extreme pain. In well-advanced cases, sharp pain is often reported when gripping a racket or even shaking hands.
Typical History
Tennis elbow, like most overuse conditions, develops gradually over several months. It may flare up suddenly as a result of increased intensity of activity, such as competing in a tennis tournament. If the injury is not the result of a racket sport, look for repetitive motion in the client's daily activities.
Relevant Anatomy
In most cases, the primary injury is tendinopathy of the extensor carpi radialis brevis (ECRB) tendon, just distal to its attachment on the lateral epicondyle. The rest of the wrist and finger extensors may be affected by the presence of tennis elbow, either by becoming hypertonic or by becoming inhibited because of pain. See figure 7.12 for illustrations indicating the wrist and finger extensors.
Figure 7.12 Wrist and finger extensors.
Extensor Carpi Radialis Brevis
The extensor carpi radialis brevis (ECRB) originates from the common extensor tendon at the lateral epicondyle of the humerus and inserts into the dorsoradial aspect of the base of the third metacarpal bone. Actions include extension of the wrist (with the ECR longus and ulnaris) and assisting radial deviation (abduction).
Extensor Carpi Radialis Longus
The extensor carpi radialis longus (ECRL)originates on the distal third of the lateral supracondylar ridge of the humerus, lying between the origin of the brachioradialis and the lateral epicondyle and inserts into the dorsoradial aspect of the base of the second metacarpal bone. Actions include extending the wrist (along with the ECR brevis and ulnaris) and assisting radial deviation (along with the flexor carpi radialis).
Supinator
The supinator originates from the posterior ulna, the lateral epicondyle, ligaments of the elbow and radioulnar joint, and the anterior capsule of the humeroulnar joint and inserts into the anterolateral aspect of the radius, just distal to the insertion of the biceps brachii. Actions include primary supinator of the hand and forearm; with the elbow flexed, the biceps brachii assists supination and assists elbow flexion when the hand is in neutral.
The radial nerve passes through the supinator muscle, and radial nerve entrapment may create symptoms similar to tennis elbow. Trigger points in the supinator may create referred pain that mimics tennis elbow and can be deactivated as part of the overall treatment for tennis elbow. Fun fact: Because supination is a stronger action than pronation, bolts and screws are designed to tighten by supination of the right forearm (righty-tighty, lefty-loosey).
Anconeus
The anconeus originates from the posterior aspect of the lateral epicondyle of the humerus and inserts into the lateral aspect of the olecranon process and the proximal posterior ulna. Actions include assisting triceps in extension of the elbow and assisting stabilization of the elbow joint during supination and pronation. The anconeus is thought to be secondarily involved in chronic cases of tennis elbow when additional stress placed on it results in compensation or inhibition of the extensor carpi radialis brevis.
Brachioradialis
The brachioradialis originates from the upper two-thirds of the supracondylar ridge of the humerus and inserts into the lateral radius, just proximal to the styloid process. Actions include flexion at the elbow, especially when the hand is in the neutral position; it may assist resisted pronation and supination. The brachioradialis may be secondarily involved with tennis elbow because of its proximity to the extensor carpi radialis longus.
Assessment
Observation
In severe cases, visible swelling over the lateral epicondyle may be present.
ROM Assessment
Active motion at the wrist consists of flexion, extension, abduction (radial deviation), and adduction (ulnar deviation). Depending on the severity of the injury, these motions may or may not cause pain. Passive motion is generally pain free except for wrist flexion, which may stretch painful tissues on the extensor side of the forearm, especially with the elbow extended.
Resisted extension of the wrist is painful. Resisted radial deviation may also be painful.
Manual Resistive Tests
The athlete, sitting or standing, places her wrist in neutral, forearm pronated. The examiner grasps the lateral elbow with one hand, and the other hand provides resistance as the athlete attempts to extend the wrist (see figure 7.13). This isometric contraction should begin slowly and build to a strong engagement of the target muscles. With the elbow flexed, the test will engage the ECR brevis more fully; with the elbow extended, the test will focus more on the ECR longus. Pain or weakness is a positive finding. Resisted extension of the middle finger (also known as Maudsley's test) is commonly positive for pain or weakness in tennis elbow (Fairbank and Corlett 2002) (see figure 7.14). If no pain occurs, the examination widens to include the other muscles that might cause lateral epicondyle pain, such as the supinator, brachioradialis, and anconeus.
Figure 7.13 Resisted wrist extension test: with (a) elbow flexed and (b) elbow straight.
Figure 7.14 Middle-finger extension test.