Dave is an age-group national competitor in tennis. Two years ago, he was 2nd in his age-group (70-75) in Houston, Texas, and this past year he was 3rd at the national championship held in Cleveland, Ohio.
Dave arrived at my office complaining of L lateral elbow pain. He was experiencing pain while playing, especially when hitting backhand, and also after playing. He indicated that he was using ice after playing to reduce both discomfort and inflammation, but wasn’t having much success relieving the condition.
At first, I thought he might have gotten the injury bull fighting in Mexico (you know, waving that cape, wrist extension/supination, and all) but after agonizing for 30 seconds, I decided to go with the possibility of Lateral Epicondylitis (tennis elbow).
Lateral Epicondylitis is an overuse condition involving the extensor muscles that originate on the lateral epicodylar region of the distal humerus. It is more properly termed tendinosis that specifically involves the origin of the extensor carpi radialis brevis muscle. Any activity involving wrist extension or supination can be associated with overuse of the muscles originating at the lateral epicondyle. Tennis has been one of the activities most commonly associated with the disorder, (Waslaski, 2012).
I was playing a hunch, so I started by assessing range of motion. In my opinion, this condition usually occurs because the wrist and hand flexors are short, strong, and tight…resulting in weak and inhibited wrist extensors. If this is the case, I also think it’s vital to first release the wrist flexors and forearm pronators, in order to bring the weak, inhibited or overstretched wrist extensors and supinator back to normal resting muscle lengths.
I began by assessing both the elbow and wrist single-plane movements.
AROM for both elbow single-plane movements, elbow flexion and extension, were WNL at 145˚ and 0˚, respectively.
PROM for both elbow single-plane movements, elbow flexion and extension, was normal tissue-on-tissue approximation and bone-on-bone, respectively.
No pain was elicited during RROM testing of elbow flexion and extension.
AROM for wrist flexion was WNL at 80-85˚. PROM was soft tissue stretch. RROM elicited no pain.
*AROM for wrist extension was a bit restricted at about 55-60˚. PROM was soft tissue stretch. RROM produced 5/10 pain in the extensor carpi radialis brevis-longus/supinator area.
AROM for wrist pronation was WNL at 80-85˚. PROM was soft tissue stretch. RROM elicited no pain.
*AROM for wrist supination was WNL at 90˚. PROM was soft tissue stretch. RROM produced 4/10 pain in the extensor carpi radialis brevis-longus/supinator area.
AROM for wrist radial deviation was WNL at 20˚. PROM was a normal abrupt, ligamentous end-feel. RROM produced some 4/10 pain, again in the extensor carpi radialis brevis-longus/supinator area.
AROM for ulnar deviation was WNL at 35˚. PROM was a normal abrupt, ligamentous end-feel. RROM elicited no pain.
I decided to begin the treatment by releasing the wrist flexors, flexor carpi radialis, flexor carpi ulnaris, and palmaris longus. I started with myofascial release, working from elbow toward the wrist. This included myofascial spreading and compression broadening of the forearm and wrist flexors.
I didn’t come across any trigger/tender points so I continued by releasing the flexor retinaculum, sometimes known as the transverse carpal ligament. I followed this with wrist joint play (arthrokinetics). To complete the flexor release, I tested RROM for scar tissue/muscle strain, but found pain-free movement only.
At this point, I felt I had released the wrist flexors/forearm pronators, thereby taking the tension off the weak, inhibited, or overstretched wrist extensors and forearm supinator, and creating the opportunity to put these muscles back where they belonged (in terms of being overstretched).
I proceeded with myofascial release techniques and compression broadening of the wrist extensors, working from distal to proximal. My intention was to try to get this group back to their normal resting length. As I worked through this group, I did not come across any muscle belly trigger points, so I checked for pain-free movement, and found it so. I then tested RROM for wrist extension and found that it was not pain-free. Dave indicated some pain in the extensor carpi radialis brevis-longus/supinator area.
I utilized a multi-directional friction technique on the area for 20-30 seconds to soften the collagen, and then checked for pain-free movement. Dave indicated that the pain had diminished, but was not completely gone, so I went back to the multi-directional friction technique but work deeper and slower to soften the deeper layers of collagen.
I tested RROM again, and got a pain-free response, so I proceeded with an eccentric scar tissue alignment technique beginning with two finger resistance and increasing the resistance each time the movement was pain-free.
Before Dave left the office, I instructed him in stretching the wrist flexors/forearm pronator and strengthening the wrist extensors and supinator.
Dave continues to compete 2-3 times a week, pain-free.