Tennis elbow is more likely a tendinosis than a tendinitis. A lateral tennis elbow should be called epidondylosis. If we wanted to be even more correct, since the epicondyle is not inflamed, the word epicondyle should be omitted. Nirschl1 refers to epidondylitis as "lateral or medial tennis elbow tendinosis."
In my last article in Dynamic Chiropractic, November 6, 1992, it was stated that research had shown that in order for a tendinitis to occur, it was necessary that blood vessels be disrupted as in a tear of a tendon or ligament. It was stated that in the so-called tendinitis of many shoulder and elbow conditions there were rarely any polymorphonuclear cells or lymphocytes found. The inflammatory process usually described with the typical tendinitis has been based on the model of the inflammatory process that occurs with an open wound.
But when the injury to a shoulder, elbow, patellar or achilles tendon is due to a non-traumatic, chronic overuse causation, the typical inflammatory process that occurs in an open wound does not occur. Instead, a non-inflammatory intratendinous collagen degeneration occurs at the bone-tendon or muscle-tendon location. What occurs is an edematous, friable tissue called "angiofibroblastic tendinosis."1 Nirschl states that in advanced lesions, chronic inflammatory cells may appear in the supporting fibroadipose, connective, and even skeletal muscle tissues and tendon which represent new or organizing granulation tissue and fibrous scar tissue.2 In other words, different from the usually described inflammatory lesion, fibrosis or scar tissue may occur only in the very advanced stage and not be the principle pathology of the overuse chronic degenerative tendon lesion.
The main theory as to why friction massage works in tendons has been based on its effect on scar tissue. While this may still be a rationale for friction massage, it is apparent that the other theories as to why friction on tendons and muscles works may be more pertinent. Cyriax's concept of friction was based on traumatic hyperemia which results in the reduction of edema in chronically irritated tissue and the freeing of adhesions both present and potential.3 Clearly friction is in some way affecting angiofibroblastic tissue in a way not related to breaking down adhesions. This may explain why some patients get well even though friction may have been applied in a circular direction than exactly across the fibers.
Although clinically, while I have found that frictioning at a right angle to the fibers is definitely more potent, frictioning a chronic bursa does not have to be done at any particular angle. Obviously, there is still much more to know as to why friction is so effective on chronic soft tissue lesions. One possibility may be related to similarities as to why therapeutic exercise is beneficial for sports-induced inflammation and injury. Exercise (friction) produces a load which causes collagen fibers to transmit physical signals "inducing changes in cellular metabolism and synthesis of proteoglycans and matrix."4
Dr. Nirchl1 who has operated on over 750 cases of elbow tendinosis has located the primary and secondary pathologic areas involved on both the medial and lateral elbow. These locations are of extreme value as to where friction will be most effective.
For lateral tendinosis, the primary area is the extensor carpi radialis brevis. He states that the "patholoic tissue often encompasses the entire origin of the extensor brevis to the level of the radial head. In approximately 35 percent of cases, pathologic change will be noticed in the anterior underside of the extensor aponeurosis." The most common area to friction is at the brevis origin at the anterior ridge of the epicondyle which is just distal to the epicondyle. The secondary area is the extensor digitorum communis as it comes off the common extensor tendon from the lateral epicondyle.
For medial tendinosis, the primary areas are the pronator teres, flexor carpi radialis, and palmaris longus close to the attachment of the medial epicondyle. Note that the pronator teres is the most proximal of the tendons going from medial to lateral from the epicondyle in almost a right angle. If this area is the most tender, it is important to friction across the fibers which would be in a direction up towards the humerus or axillary area. The secondary area is the flexor carpi ulnaris which would require a more medial than vertical friction angle.
References
Editor's Note:
Dr. Hammer will conduct his next soft tissue seminar on March 13-14, 1993, in Raleigh, North Carolina. You may call 1-800-359-2289.
Dr. Hammer's new book, Functional Soft Tissue Examination and Treatment by Manual Methods: The Extremities, is now available. Please see the Preferred Reading and Viewing list on pages xx, Part #T-126 to order your copy.
When sports chiropractors first appeared at the Olympic Games in the 1980s, it was alongside individual athletes who had experienced the benefits of chiropractic care in their training and recovery processes at home. Fast forward to Paris 2024, where chiropractic care was available in the polyclinic for all athletes, and the attitude has now evolved to recognize that “every athlete deserves access to sports chiropractic."
It is estimated that 61% of patients with CTS avoid taking surgical options due to postoperative complications and costly surgical procedures. Chiropractic care offers a comprehensive and effective treatment for carpal tunnel syndrome, addressing the condition from multiple angles. Recent studies also have unveiled a game-changing adjunct to chiropractic treatments for CTS: nerve flossing.
Some doctors thrive in a personality-based clinic and have a loyal following no matter what services or equipment they offer, but for most chiropractic offices who are trying to grow and expand, new equipment purchases help us stay relevant and continue to service our client base in the best, most up-to-date manner possible. So, regarding equipment purchasing: should you lease, get a bank loan, or pay cash?
