How do you treat tennis elbow?
Blog 2 in a series of 3
In blog 2 of this series, we will look at possible myofascial and manual therapy treatment techniques to address the causes and consequences of tennis elbow. We discuss dry needling, percutaneous electrolysis, and the Mulligan Concept based on the literature and successful experiences of therapists and patients. The techniques indicated for your patient and the combination thereof depend on each patient and the extent of their complaint.
Dry needling for epicondylitis lateralis
Research shows that people with tennis elbow always have active trigger points in one or more forearm muscles compared to people without lateral elbow pain. The trigger points, which are very localised muscle cramps, not only cause localised pain but also radiating pain to the dorso-lateral forearm and the lateral epicondyle. The study also demonstrated a link between active trigger points to pressure pain tolerance. Specifically, the more active trigger points present, the lower the pressure pain tolerance in the lateral epicondyle.1 So, treatment of the active trigger points is recommended. Manual treatment is possible, but shock wave therapy and dry needling are also suitable. Physiotherapist Chris opts for dry needling:
“Provocation of active trigger points induces the recognisable myofascial radiating pain in the forearm. Dry needling resets these trigger points and the circle is broken. Tennis elbow is usually a result of overloading the chain, so I also often opt to use needling on the neck-shoulder girdle for a segmental approach.”
Dry needling reduces pain and improves function in patients with tennis elbow. It also has a positive effect on pressure pain tolerance and grip strength.2This is also patient Bram’s experience:
“It wasn’t just the pain in my elbow that limited my activities, it was also the painful tense feeling in my forearm. After treatment with dry needling, my forearm soon felt much looser and less painful. I was also able to tolerate touch better and had more strength.”
So, dry needling is experienced as a successful part of the treatment of tennis elbow by both therapist and patient. However, if dry needling does not produce the desired effects quickly enough, the therapist may still choose to intensify the intervention by going a step further with ultrasound-guided percutaneous electrolysis.
What is percutaneous electrolysis and how does it contribute to tennis elbow recovery?
Percutaneous electrolysis is a minimally invasive technique where a thin needle is inserted and ultrasound is used to guide it to the treatment area. The needle administers a direct current to trigger a nonthermal electrochemical reaction. Currently, the technique is mainly used to treat tendinopathies and active trigger points. The intended effect is to activate the natural recovery mechanisms. Physiotherapist Bert regularly uses the technique.
“In the difficult case of tennis elbow, using percutaneous electrolysis with Gymna Acure to treat trigger points in affected extensors has remarkably better results than just dry needling. The total recovery time is shortened with fewer therapeutic sessions. Highly recommended!”
Recent research suggests that percutaneous electrolysis combined with an eccentric exercise programme is even more effective in improving pain and pressure pain tolerance in the short and medium term.3Despite this, patients are sometimes reluctant to try percutaneous electrolysis. However, according to patient Wout, that is a mistake. Wout explains, “My initial hesitation for the proposed treatment turned out to be just wrong. I felt a difference after just three sessions. If I keep improving, I’m going to get back into paddle ball. Even after the somewhat nagging discomfort in the first two days after the treatment, I’m quite enthusiastic about it. I’m even trying to convince my friend who has the same complaints to take this treatment.”
However, just tackling trigger points and a local approach to the tendon may not be enough. Sometimes, dysfunctional (surrounding) joints prolong the problem. So, a precondition for local recovery is to tackle such factors that impede progress. Using manual therapy to just treat this is very beneficial. Nonetheless, using it more broadly can also make an important contribution to the recovery from tennis elbow. One example is the Mulligan Concept, which is all about recovering the function of a joint and its associated soft tissues.
The Mulligan Concept for epicondylitis lateralis
The Mulligan Concept assumes a ‘positional fault’ or ‘tracking problem’ in a joint. The so-called Mobilisation With Movement (MWM) can solve that problem. In an MWM, the therapist corrects the position of the joint using translation and/or rotation while the patient performs the movement that provokes the complaint. If indicated, using this technique is 100% painless.
Physiotherapist Jasmine explains, “I often use MWMs to achieve excellent results with tennis elbow. The fact that the patient’s painful movement can be performed immediately without pain is not only a great relief for the patient, but also motivates them to exercise and thus recover more quickly.”
Research shows that adding MWMs to the treatment of lateral epicondylitis has positive effects on pain and pain-free pinch strength.4 Patient Katja also notices these positive effects.
“I can immediately move again painlessly and functionally thanks to this technique. What’s even better is that if I have problems, I can also use the technique quickly and easily at home. I correct the position of my elbow joint and can then practise the provoking movement without pain.”
In summary, the therapist must make choices depending on the patient’s pathology and available therapeutic techniques. In blog 1 of this series, we previously discussed TECAR therapy. However, Shockwave therapy, percutaneous electrolysis, or Mulligan’s manual therapy mobilisations can also offer the patient a short- and long-term solution for tennis elbow.
More info on percutaneous electrolysis
Do you think percutaneous electrolysis therapy may be effective for one or more of your patients? Would you like to receive more information and/or a personal recommendation? Please feel free to contact us.
 Fernández-Carnero J, Fernández-de-Las-Peñas C, de la Llave-Rincón AI, Ge HY, Arendt-Nielsen L. Prevalence of and referred pain from myofascial trigger points in the forearm muscles in patients with lateral epicondylalgia. Clin J Pain. 2007 May;23(4):353-60. doi: 10.1097/AJP.0b013e31803b3785. PMID: 17449997.
 Navarro-Santana MJ, Sanchez-Infante J, Gómez-Chiguano GF, Cleland JA, López-de-Uralde-Villanueva I, Fernández-de-Las-Peñas C, Plaza-Manzano G. Effects of trigger point dry needling on lateral epicondylalgia of musculoskeletal origin: a systematic review and meta-analysis. Clin Rehabil. 2020 Nov;34(11):1327-1340. doi: 10.1177/0269215520937468. Epub 2020 Jun 23. PMID: 32576044.
 Rodríguez-Huguet M, Góngora-Rodríguez J, Lomas-Vega R, Martín-Valero R, Díaz-Fernández Á, Obrero-Gaitán E, Ibáñez-Vera AJ, Rodríguez-Almagro D. Percutaneous Electrolysis in the Treatment of Lateral Epicondylalgia: A Single-Blind Randomized Controlled Trial. J Clin Med. 2020 Jul 1;9(7):2068. doi: 10.3390/jcm9072068. PMID: 32630241; PMCID: PMC7408752.
 Reyhan AC, Sindel D, Dereli EE. The effects of Mulligan’s mobilization with movement technique in patients with lateral epicondylitis. J Back Musculoskelet Rehabil. 2020;33(1):99-107. doi: 10.3233/BMR-181135. PMID: 31104005.