This contribution by Shea Shulman, LMT, CLT is an excellent example of what Periostal Massage can do for patients. Overall, any pathological conditions associated with trauma or inflammation in the periosteum must be treated by Periostal Massage, which was specifically designed for abnormalities like epicondylitis, arthritis, styloiditis, etc. It is very difficult and frequently impossible for the therapist to achieve stable clinical results for these pathological conditions without using Periostal Massage.

Another important point which I would like to emphasize is the excellent clinical reasoning Shea exhibited for this case. She didn’t jump on the application of Tennis Elbow MEDICAL MASSAGE PROTOCOL right away. She made the correct assumption that low grade chronic irritation of the brachial plexus may trigger Tennis Elbow. As a responsible therapist she eliminated other potential causes first before narrowing her treatment to the local application of a MEDICAL MASSAGE PROTOCOL which she successfully used.

Dr. Ross Turchaninov, Editor in Chief



Client:  57 year old male
Chronic elbow pain at the lateral epicondyle on his right arm.


This particular client has received regular massage at our clinic for a couple of years.  He has often complained of tension in his forearms and some elbow pain. At home, he spends a lot of time typing on the computer as well as working in his yard.  His forearms were always worked in our massage sessions, relaxing them and stretching them.

After not being in for a couple of months, he returned with severe elbow pain.  Prior to the pain progressing, he spent most of a week redoing his back yard.  This included trimming trees and bushes, pulling weeds, putting in back yard pavers and planting new plants.  When he arrived for his session, the problem was to the point that he could not pick up simple things around the house, like a can of vegetables, without feeling intense pain on the lateral side of the right elbow.

To formulate the correct MEDICAL MASSAGE PROTOCOL I needed to isolate its trigger. For this reason I needed to rule out the possible irritation of the brachial plexus by slightly tensed anterior scalene and/or pectoralis minor muscles. Applications of Wartenberg’s Test, Anterior Scalene Trigger Point Test, Pectoralis Minor Trigger Point Test and Wright’s Test were negative.

Thus it was obvious that I was dealing with local pathology in the right lateral epicondyle due to chronic overuse.

Local examination of the lateral epicondyle confirmed a positive Wrist Extension Test and Trigger Point Test for the extensor digitorum muscle. At the same time, the Supination Test was negative.

Thus the local examination of the lateral elbow confirmed the presence of local trauma at the insertion of extensors at their insertion into the lateral epicondyle. My short examination also revealed another important piece of diagnostic information. The tension in the supinator muscle didn’t contribute to the clinical picture and it meant that the deeper layer of the dorsal forearm muscles wasn’t involved yet.

MEDICAL MASSAGE PROTOCOL: Lateral Epicondylitis (Tennis Elbow)

As this was my very first attempt at treating this condition using Periostal Massage, and my client was already in a lot of pain, I was quite nervous about performing this method at the end of this protocol.  However, I was very thorough in my assessment and confident that the Periostal Massage would heal his tennis elbow.  Only because I had complete faith that Medical Massage would work was I okay with the fact that I was inflicting severe pain on him at the end of each session.

Prior to setting up the series of sessions for his elbow, I gave him a detailed explanation as to why we needed to perform the Periostal Massage, I explained that this final part of the session would be very painful and that the next day he would be in much more pain than he was prior to the treatment.

I started the session working on the tissues of the dorsal forearm on a layer by layer basis to reduce protective tension developed in the extensors and fascia due to the chronic pain. Only after mobilizing soft tissues and restoring the anatomical length of involved muscles I started Periostal Massage at the end of each session.

After the first session, I called my client the following afternoon.  He was definitely sore from the therapy, but he could tolerate it.   We gave a 3 day break before doing the 2nd session to be certain the skin was no longer tender in the area.  After the 2nd session, he was again in more pain, but it was manageable.  We gave 2 days off this time.  During the 3rd session, I decided to use my knuckle instead of my thumb to perform the Periostal Massage.  I was reluctant in the first 2 sessions to be so aggressive, but I also did not want to risk being too conservative and have the therapy fail.  After using my knuckle to perform the Periostal Massage, he was MUCH more inflamed the next day.  We ended up waiting another 3 days before he returned.

By the 5th session, I believe we were both starting to wonder if the therapy was going to work.  He was tolerating the therapy and understood the science behind it, but getting a little worried that his elbow continued to hurt.  However, after the 5th session, something happened.  When he returned for his 6th session, he said that he was noticing less pain when picking things up.  We completed his 6th session and I decided to give the elbow a break to allow it to continue healing (I hoped).  Even though I had attended Medical Massage Seminars and read the Medical Massage textbook book over and over, I felt like I was winging it throughout this entire process.  I was not certain I had done anything quite right, but my gut said that this would work and my client was putting a lot of faith in me.

After a week off of therapy, his elbow was significantly better.  We decided to do 2 more sessions to hopefully seal the deal.  And guess what…it worked!  Approximately 6 months later he returned to the office with elbow pain again – but this time in the OTHER elbow.  Though he has continued to work in his yard and spend many hours a day typing, the work has held.  It seems that the elbow is now stronger than it was before.

I do not know if being more aggressive during the first 2 sessions would have expedited the process.  Regardless, the process worked and I am now much more confident when working on this type of injury.

Shea Shulman LMT, CLT

Shea Shulman Jan 2015 A
Shea is a Licensed Massage Therapist and Certified Lymphedema Therapist specializing in Medical Massage.  She is passionate about learning and has completed an average of 100 hours of continuing education per year over the last 5 years.  It was not until taking her first course with Dr. Turchaninov  and Oleg Bouimer (Advanced Sports Massage for Injuries) that she started to truly understand what kind of impact her work could have on pain and dysfunction.

Shea co-owns a practice with 11 therapists in Sarasota, Florida (Massage Therapy Connections) where she and her business partner are dedicated to teaching other therapists about Medical Massage.  It has become an integral part of their philosophy and business.  Through their efforts, they hope to help make Medical Massage a more utilized tool in health care.

Category: Case Studies