Trigger points and tennis elbow: cause, diagnosis and treatment

What are tennis elbow and trigger points?

Trigger points (lateral epicondylitis)

Tennis elbow is the irritation or injury to the outside of the elbow where many of your forearm muscles are attached. This attachment is called the lateral epicondyle, so has the technical name of lateral epicondylitis. The condition is common in tennis players, hence the name tennis elbow, but it can be caused by any repetitive activity involving forearms and gripping. It is even a common problem in those continually using a computer.

(Myofascial) trigger points

How trigger points cause tennis elbow and the problems when this is ignored

We will start by showing you the simple model of how tennis elbow forms that you’ll find in medical journals and most articles or videos. This ignores the effects of trigger points. We'll then show you how trigger points contribute and discuss the problems ignoring them cause.

The simple medical version of tennis elbows

The complete cause of tennis elbow

As well as creating stress upon the attachment at the lateral epicondyle the repetitive activities cause muscles to tighten and develop trigger points. As discussed below these:

• cause tension at the elbow, and
• cause pain the mimics tennis elbow.

Causing abnormal tension

As discussed, trigger points can cause tennis elbow by causing abnormal tension in the forearm muscles that attach to the lateral epicondyle at the outside of the elbow.

Causing pain that mimics tennis elbow

The evidence that trigger points are a big cause of tennis elbow

There is a large amount of scientific evidence showing that trigger points are heavily involved in tennis elbow. Despite this Medical journals typically ignore them, and standard treatments typically just include rest, ice, non-steroidal anti-inflammatory drugs, corticosteroid injections, exercises and stretching (4,5)⁠. Why are trigger points ignored? You can't treat trigger points with drugs and selling pain killers and inappropriate tennis elbow treatments is big business.

The evidence

• Scientists have established that activity causes trigger points and that they cause muscles to tighten (1,2,6–8)⁠. Tightness obviously causes stress where the muscles attach.
• Further, several studies have shown that tennis elbow sufferers have large numbers of trigger points compared with non-sufferers (9–11)⁠, and
• trigger point therapy is shown to provide effective relief (3,12–14)⁠.

The problems ignoring trigger points cause

It's very simple. Doctors tell you to rest and take pain killing drugs expecting this to relieve the stress and the elbow to heal, but instead the abnormal tension and referred pain remains. They'll start blaming the elbow for not healing, then start rubbing it, sticking in needles or zapping it with laser, but of course that's useless because the abnormal rension still won't let it heal. Eventually they get to sell you a life time of drugs, needles, useless therapies and maybe even a surgery. Everyone benefits- except the patient.

How to tell if you have tennis elbow and trigger points

Tennis elbow diagnosed (do you have tennis elbow)

Lets look at how tennis elbow is diagnosed. The tests are something simple you can do yourself, but please discuss them with a professional.

Symptoms of tennis elbow

The symptoms of tennis elbow are pain at the outside of your elbow, aggravated by activities such as bending back your wrist or fingers, or by gripping.

Simple tests for tennis elbow

There are two basic tests a doctor will do to diagnose tennis elbow.

Examining for tenderness

Examine the outside of your elbow. It will be very tender at the bony bump (lateral epicondyle) and for 1-2 cm towards your wrist (the tendon).

Provocation tests

There are a couple of tests with the impressive sounding names Mills and Cozens tests, but these are basically i) bending your wrist forward to tighten the muscles at the back of your forearm that attach to the lateral epicondyle, and ii) bending the wrist back the other way against resistance. These pull on the area injured in tennis elbow, so if they cause pain it is considered positive.

Are trigger points involved in your tennis elbow

If you have tennis elbow we have two simple tests for trigger point involvement. The first is to simply check for trigger points to see if you have them. The second is to see if treating the trigger points relieves your tennis elbow. here are the details.

Practical advice on Tennis elbow prevention and treatment

Tennis elbow treatment

If you have tennis elbow we have a very comprehensive article How to treat your tennis elbow at home

Tennis elbow prevention

If through sport or work you use your forearm muscles a lot it is important to understand that tennis elbows and the associated abnormal tension build up slowly, then it takes further time with this abnormal stress for the elbow to become inflamed and start feeling sore. Because of this we thoroughly recommend that as a preventative measure you regularly do the forearm muscle massages shown in our video

References

1. Shah J et al. Myofascial Trigger Points Then and Now: A Historical and Scientific Perspective. HHS Public Access. 2015;7(7):746–61.
2. Celik D, Mutlu EK. Clinical implication of latent myofascial trigger point topical collection on myofascial pain. Curr Pain Headache Rep. 2013;17(8).
3. Trivedi P, Sathiyavani D, Nambi G, Khuman R, Shah K, Bhatt P. Comparison of active release technique and myofascial release technique on pain, grip strength & functional performance in patients with chronic lateral epicondylitis. Int J Physiother Res. 2014;2(3):488–94.
4. Smidt N, Windt DAWM Van Der, Assendelft WJJ, Devillé WLJM, Bos IBCK. Corticosteroid injections , physiotherapy , or a wait-and-see policy for lateral epicondylitis : a randomised controlled trial. Lancet. 2002;359:657–62.
5. Johnson GW, Cadwallader K, Scheffel SB, Epperly TEDD. Treatment of Lateral Epicondylitis. Am Fam Physician. 2007;(76):843–50.
6. Jafri MS. Mechanisms of Myofascial Pain. Int Sch Res Not. 2014;2014:1–16.
7. Zhuang XQ, Tan SS, Huang QM. Understanding of myofascial trigger points. Chin Med J (Engl). 2014;127(24):4271–7.
8. Bron C, Dommerholt JD. Etiology of myofascial trigger points. Curr Pain Headache Rep. 2012;16(5):439–44.
9. Fernández-Carnero J, Fernández-De-Las-Peñas C, De La Llave-Rincón AI, Ge HY, Arendt-Nielsen L, Johnson GW, et al. Prevalence of and referred pain from myofascial trigger points in the forearm muscles in patients with lateral epicondylalgia. Clin J Pain . 2007;23(4):353–60.
10. Aggarwal A, Daniel J, Palekar TJ. Prevalence of Myofascial Trigger Points in Brachioradialis, Biceps Brachii, Triceps Brachii, Supinator and Extensor Carpi Radialis Brevis in Lateral Epicondylitis. Indian J Physiother Occup Ther - An Int J. 2020;(1):14–8.
11. Fernández-Carnero J, Fernández-De-Las-Peñas C, De La Llave-Rincón AI, Ge HY, Arendt-Nielsen L. Bilateral myofascial trigger points in the forearm muscles in patients with chronic unilateral lateral epicondylalgia: A blinded, controlled study. Clin J Pain. 2008;
12. kotteeswaran k. EFFECT OF MYOFASCIAL TRIGGER POINT RELEASE THERAPY AND ACTIVE STRETCHING ON PAIN AMONG LATERAL EPICONDYLITIS PARTICIPANTS. Int J Res Anal Rev. 2019;6(2):184–8.
13. Khuman R. Myofascial release technique in chronic lateral epicondylitis: a randomised controlled study. Int J Heal Sci Res. 2013;3(7):45–52.
14. Ajimsha M. Effectiveness of myofasial release for lateral epicondylitis in computer professionals. Arch Phys Med Rehabil. 2012;93(4):604–9.