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Ta k e 5 a n d t r y A B M P F i v e - M i n u t e M u s c l e s a t w w w. a b m p . c o m / f i v e - m i n u t e - m u s c l e s . 97 late tendon disrepair and degenerative tendinopathy. Following are some recommended treatment strategies at the different stages. Stage 1 • Pharmacologic interventions like NSAID • Tendon load management (reducing the offending load and rest from offending activities) Stage 2 • Biologic therapies • Shockwave therapy • Exercise (emphasizing eccentric loading on the muscle-tendon unit) • Ultrasound • Massage So what role does massage play in epicondylitis treatment? One of the most commonly used massage treatment strategies is deep transverse friction (DTF). Originally it was thought that the primary benefit of DTF was helping to realign scar tissue from the torn tendon fibers. However, that idea has now fallen out of favor as it has become clear that torn tendon fibers rarely play a role in epicondylitis. Also, it's not clear that realigning scar tissue fibers with thumb friction is even possible because of the multiple tissues between the thumb and the damaged tissue. Some research studies that have looked into friction massage have shown that there appears to be some degree of enhanced fibroblast proliferation as a result of the pressure and movement of the friction massage. So in LE, pressure and movement on the impaired extensor tendons could be encouraging rebuilding of the damaged collagen structure within the tendon. Another possibility is that the key benefits of friction massage are not only mechanical (pressure and movement), but also help in pain reduction through neurological processes. There is a neurological principle called conditioned pain modulation (CPM), which suggests that in certain cases, a low to moderate pain stimulus can essentially act as a distractor and reduce other pain sensations. 4 Friction massage is usually performed at a level that can be somewhat uncomfortable, so its benefit in pain reduction could be at least partially due to CPM. An important aspect of reducing the tendon load to encourage healing is to decrease chronic hypertonicity in the associated muscles. Reducing hypertonicity is another important role that massage can play in treating epicondylitis. A wide variety of techniques can be effective at helping reduce hypertonicity in the wrist extensor muscles. Superficial applications that appear particularly effective are good compressive effleurage and broad sweeping cross-fiber applications. As treatment progresses, deeper longitudinal stripping methods, especially those with a small contact surface like a thumb, fingertip, or pressure tool, are very effective. Active engagement lengthening techniques appear to bring good results as well. In this technique, the practitioner applies a deeper longitudinal stripping technique to the wrist extensor muscles while they are engaged in an eccentric (lengthening) action (see video). Engaging the muscle in an eccentric contraction involves greater neurological input along with the massage technique. This greater neurological input may serve to enhance a pain-reducing process called descending modulation. We know this treatment is particularly effective, and it may be that much of this effect is due to the enhanced descending modulation. Lateral epicondylitis can become a debilitating condition, and because it is often related to occupational injuries, the condition can provoke significant anxiety. It may appear as if a person, such as a massage therapist, will no longer be able to continue performing their chosen occupation. When caught early, activity modification and reduction of the mechanical load can halt the progression of the condition. If it has progressed further, massage is an ideal intervention for enhancing physiological change, as well as managing psychological and social impacts of this common malady. Notes 1. Wilson C. Lai et al., "Chronic Lateral Epicondylitis: Challenges and Solutions," Open Access Journal of Sports Medicine 9 (October 2018): 243–51, 2. Evelyn Bass, "Tendinopathy: Why the Difference Between Tendinitis and Tendinosis Matters," International Journal of Therapeutic Massage and Bodywork 5, no. 1 (March 2012): 14–17. 3. J. L. Cook and C. R. Purdam, "Is Tendon Pathology a Continuum? A Pathology Model to Explain the Clinical Presentation of Load-Induced Tendinopathy," British Journal of Sports Medicine 43, no. 6 (June 2009): 409–16, 4. D. Yarnitsky, "Conditioned Pain Modulation (The Diffuse Noxious Inhibitory Control-Like Effect): Its Relevance for Acute and Chronic Pain States," Current Opinion in Anaesthesiology 23, no. 5 (October 2010): 611–15, Whitney Lowe is the developer and instructor of one of the profession's most popular orthopedic massage training programs. His text and programs have been used by professionals and schools for almost 30 years. Learn more at Watch "Active Stripping on Forearm"

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