Myofascial pain in lateral epicondylalgia: A review

doi:10.1016/j.jbmt.2013.02.003

Journal of Bodywork and Movement Therapies

Volume 17, Issue 4, October 2013, Pages 434-439

https://doi.org/10.1016/j.jbmt.2013.02.003 Get rights and content

Summary

Background

There is an ongoing debate about the myofascial component, characterized by the presence of myofascial trigger points (MTrPs) in lateral epicondylalgia (LE).

Objectives

To review current evidence of the association between myofascial pain and LE, including efficacy of treatment, focusing on myofascial pain.

Methods

PubMed, Google Scholar and PEDro databases were searched without search limitations from inception until October 2012 for terms relating to LE and MTrPs.

Results

Two observational studies showed a high prevalence of MTrPs in LE patients compared to healthy controls. Three randomized controlled trials demonstrated significant improvement in pain and functional outcomes after application of soft tissue techniques, focusing on the myofascial component.

Conclusion

Myofascial pain and MTrPs may be part of the LE etiology. Treatment focusing on the myofascial component seems to be effective in reducing pain and improving function in patients with LE. Additional trials are essential to attain a solid conclusion.

Introduction

Lateral epicondylitis (epicondylalgia) (LE), also known as tennis elbow, is a pathology characterized by pain over the lateral aspect of the elbow, and referred pain into the dorsal forearm. LE is the most commonly diagnosed elbow condition, affecting approximately 1–3% of the general population each year, with workplace activities contributing to 35–64% of all cases (Nirschl, 1992; Verhaar, 1994). The highest incidence was associated with repetitive or high load wrist and hand functions (Gabel, 1999; Levangie and Norkin, 2001; Muirhead et al., 2001).

LE places a significant economic burden on western societies, resulting in a high rate of sick leave and absenteeism (Simons et al., 1999). Although the etiology and pathology of this disorder are under debate, evidence of a tissue-based pathology includes degenerative changes at the common extensor origin consistent with tendinopathy (Khan et al., 1999). Literature reviews (Goguin and Rush, 2003; Boisaubert et al., 2004) identified more than 40 different treatments for LE (electrotherapy, ultrasound, orthotics, physical therapy, acupuncture, chiropractic manipulation, anti-inflammatory, etc.). Most studies reported inconsistent results, and no therapeutic modality seems to stand out. It is possible that the relatively low effectiveness of proposed treatments can be due to additional unidentified pathological factors.

In 1989, Chop suggested that certain LE symptoms could be attributable to myofascial trigger points (MTrP) that developed in the muscles attached to the lateral epicondyle (myofascial pain syndrome) (Chop, 1989).

Myofascial pain is a common form of pain arising from muscles or related fascia and is usually associated with MTrPs. MTrP is a highly localized, hyperirritable spot situated in a palpable, taut band of skeletal muscle fibers (Simons et al., 1999). Referred pain from MTrPs in forearm muscles produces pain features usually found in patients presenting with LE (Simons et al., 1999). However, the relationship between MTrPs in the forearm muscles and LE is still uncertain.

Hence, the aim of this paper was to review current evidence of the association between myofascial pain and LE, including the efficacy of LE treatment, focusing on myofascial pain.

Section snippets

Methods

PubMed, Google Scholar and PEDro databases were searched using predefined strategy from inception until October 2012 for the keywords shown in Table 1. Abstracts of articles mentioning one of the above keywords in the title were reviewed. Included in this review were studies of any design or methodological quality dealing with either prevalence of myofascial pain syndrome in LE or treatment by any type of manual soft tissue technique. There were no search limitations or language restrictions.

Results

The search strategy revealed 269 articles. After a review of all titles, abstracts and full texts of potentially relevant studies, five papers (two observational studies and three randomized controlled trials (RCTs)) were included in this review.

In an observational study of 20 patients with chronic (>3 months) LE and 20 healthy controls (Fernandez Carnero et al., 2007), referred pain and pain characteristics evoked from forearm muscles, were investigated. An assessor, blinded to the

Discussion

The current review included two observational studies evaluating the prevalence of MTrPs in LE patients, and three RCTs evaluating the efficacy of treatment, focusing on the myofascial component.

The first two studies (Fernandez Carnero et al., 2007; Fernandez Carnero et al., 2008) demonstrated that referred pain and pain characteristics elicited by manual examination of MTrPs in the forearm muscles, share similar patterns as persistent lateral elbow and forearm pain in patients with LE. Active

Conclusions

Reviewed observational studies provide initial evidence for the assumption that myofascial pain and prevalence of MTrPs may be part of the etiology of LE. Additional studies are needed to understand if myofascial pain in LE co-exists with common extensor tendinopathy, causes or predisposes it. We also believe that the evaluation of myofascial pain should be part of a routine clinical examination of LE.

According to the three interventional studies included in this review, treatment focusing on

Funding sources

None.

Conflicts of interest

There were no identified conflicts of interest.

Acknowledgments

The authors would like to thank Mrs. Phyllis Curchack Kornspan for her editorial services.

References (19)

M.S. Ajimsha et al.
Effectiveness of myofascial release in the management of lateral epicondylitis in computer professionals
Archives of Physical Medicine and Rehabilitation
(2012)
M.A. Blanchette et al.
Augmented soft tissue mobilization vs natural history in the treatment of lateral epicondylitis: a pilot study
Journal of Manipulative and Physiological Therapeutics
(2011)
B. Boisaubert et al.
Nonsurgical treatment of tennis elbow
Annales de Readaptation et de Medecine Physique
(2004)
J.P. Goguin et al.
Lateral epicondylitis, what is it really
Current Orthopaedics
(2003)
M.P. Jensen et al.
Comparative reliability and validity of chronic pain intensity measures
Pain
(1999)
R.P. Nirschl
Elbow tendinosis/tennis elbow
Clinics in Sports Medicine
(1992)
M.R. Nourbakhsh et al.
The effect of oscillating-energy manual therapy on lateral epicondylitis: a randomized, placebo-control, double-blinded study
Journal of Hand Therapy
(2008)
T.J. Overend et al.
Reliability of a patient rated forearm evaluation questionnaire for patients with lateral epicondylitis
Journal of Hand Therapy
(1999)
J.F. Barnes
Myofascial Release: the Search for Excellence
(1990)

There are more references available in the full text version of this article.

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ReviewMyofascial pain in lateral epicondylalgia: A review

Summary

Background

Objectives

Methods

Results

Conclusion

Introduction

Section snippets

Methods

Results

Discussion

Conclusions

Funding sources

Conflicts of interest

Acknowledgments

Archives of Physical Medicine and Rehabilitation

Journal of Manipulative and Physiological Therapeutics

Annales de Readaptation et de Medecine Physique

Current Orthopaedics

Pain

Clinics in Sports Medicine

Journal of Hand Therapy

Journal of Hand Therapy

Myofascial Release: the Search for Excellence

Review
Myofascial pain in lateral epicondylalgia: A review