This clinical case was submitted to JMS by our former student Ben Keyes, LMT, from Florida. Ben works on various somatic problems, and his main focus is sports trauma and rehabilitation. Ben is an exceptionally well-educated therapist who fully grasps the concept of Medical Massage. 

          Stable clinical Medical Massage results come from two equally important components: the correct identification of the initial trigger and an optimal blend of different treatment modalities within one session of Medical Massage. When you read Ben’s clinical case, please pay attention to his clinical thinking, which allowed him to collect the necessary data, correctly interpret it, prioritize treatment options and build up a clinical response from session to session. 

          This clinical case from SOMI’s student is an excellent example of the treatments we reference in our Periosteal Massage articles published in this and previous issues of JMS.

Dr. Ross Turchaninov, Editor in Chief

 

MEDICAL MASSAGE VS ACUTE ‘TENNIS ELBOW

by Ben Keyes, LMT, Winter Park, FL

 

Patient History:

          Patient, I successfully helped with lumbar pain before coming into the clinic complaining of pain she developed while playing tennis. She is 36 years old and has been playing tennis and practicing with a coach 3-4 times weekly for more than six months. 

 

First Appointment: Monday 

Complaints:

          The patient was experiencing pain on the lateral surface of the right elbow joint, which started as mild discomfort approximately five weeks prior. The intensity of symptoms gradually increased, leading to sharper and more frequent pain lasting long after each workout or tennis game. 

          She did not have pain throughout her arm but noticed discomfort in her right shoulder. There was no correlation between shoulder and elbow pain, and the patient was not taking any prescribed medications. The patient is sure that she has Tennis Elbow (TE).

 

Evaluation: 

          A Motor Test revealed that the grip of her right hand was noticeably weaker. The skin over the dorsal right hand felt cooler to touch than on her left. A Sensory Test indicated a sensory deficit along the C-6 Dermatome. This meant that her C-6 Sclerotome–innervation to the Lateral Epicondyle of the humerus–was most likely affected. 

          An active and passive cervical ROM test demonstrated a restriction in lateral flexion and discomfort during passive cervical extension. These sensations are not present during active extension. I performed Cervical traction and compression tests while the patient was seated, with no change in symptom intensity. A Wartenberg’s Test was negative on the left but positive on the right, sending an ache down to her right shoulder and stopping short above the elbow. A Trigger Point Test for the right ASM was negative, and all other tissue seemed normal to the touch. 

          An elbow and wrist Motor Test showed restrictions in wrist extension and forearm supination. When I eccentrically resisted wrist flexion, it created pain at the Lateral Epicondyle. I applied a Compression Test on the periosteum of the Lateral Epicondyle, and it immediately triggered a similar pain to what the patient felt during a workout or game. Thus my theory of an impacted C6 sclerotome was correct. She exhibited a positive Trigger Point Test for the Extensor Digitorum Muscle.

 

Conclusion:

          It was evident that the patient indeed had TE. Nevertheless, an evaluation pointed to mild radial nerve irritation by the anterior scalene muscle on her anterior/lateral neck as an initial trigger to the inflamed periosteum of the lateral epicondyle.

          My first goal was to decompress the brachial plexus irritated between the anterior and middle scalene muscles. I started with Medical Massage Protocol for Anterior Scalene Muscle Syndrome (ASMS), which I learned during the Science of Massage Institute’s training (Medical Massage Courses & Certification | Science of Massage Institute). 

          At the end of the first session, Wartenberg’s Test was negative on both sides. A Motor Test showed that both hands’ ability to squeeze was symmetrically restored. The Sensory deficit on the right hand and forearm was gone, and the skin’s temperature in both the hands and forearms was restored. Finally, Cervical ROM was restored with no more tightness during passive and active extension.

          The patient had an upcoming tennis tournament in five days and hoped for a quick single-session solution to her pain and dysfunction. She was disappointed that I did not work on her elbow–her primary concern. I set realistic expectations of the clinical results she could expect, considering she had already suffered from TA for five weeks before treatment.

 

Second Appointment: Wednesday 

          Two days after the first appointment, I reevaluated her arm’s functions via a Motor Test and also re-examined her skin temperature and sensory deficit. All tests appeared to be normal. However, Wartenberg’s Test was still positive but less acute on the right, and her active and passive ROMs were slightly deficient in left lateral flexion. She reported feeling the same level of pain while serving the ball.

          I again applied the ASMS protocol followed by a Wartenberg Test, which turned negative following treatment. Since she was seated and securely draped by a sheet, I examined her Deltoid Muscle through Resistance and Trigger Point Tests–I detected no abnormalities. And yet, applying a Compression Test for the pectoralis minor muscle sent new sensations down to her Right Lateral Epicondyle, which was where she felt elbow pain. Tension in the pectoralis minor muscle, similar to ASM, may irritate the brachial plexus. I, therefore, decided to address the pectoralis minor muscle with frictions, kneading, and active concentric and eccentric contractions of the Pec Minor muscle. At the session’s end, the patient reported a warm sensation traveling down her arm and into her hand.

 

Third Appointment: Friday 

          It was the day before the patient’s tournament. A friend gave her a compression sleeve to wear around the forearm distal to the elbow. She noticed a decrease in pain when she practiced the day before. As she increased her training, the pain slowly returned, and she used a forearm strap to get some relief and stability. She said that her shoulder improved after Wednesday’s session. 

          All cervical and anterior chest examinations showed no abnormalities. From the Tennis Elbow (TE)/Lateral Epicondylitis Protocol, I applied Lymphatic Drainage, friction, vibration, and percussion on the extensor muscles and Supinator muscle below her pain threshold. I also introduced large surface friction on and around the Lateral Epicondyle.

          At the end of the session, the patient exclaimed, “this is the best I’ve felt in a month!” We discussed the importance of warming up before each competition and engaging in self-lymphatic work after its end. 

          I applied Kinesiology Tape (KT) to assist her wrist flexion and supination. The purpose of the KT was to create a shearing effect on the skin to inhibit the extensor muscles, help with supination, and hopefully deter her from using the compression strap over the forearm.

 

Fourth Appointment: Monday

          The patient resumed treatment for elbow pain. She had no elbow pain during or after two matches on Saturday. The pain started during the third match, and she used sleeve compression, which helped her finish Saturday’s competitions. During the third match on Sunday, the elbow pain came back with the same intensity. 

          I repeated all initial tests, and she now tested positive for Lateral Epicondylitis pain with an active Trigger Point in the Extensor Digitorum Muscle. I confirmed she was not taking any anti-histamines or NSAID’s, and I started the Medical Massage Protocol for TE which decompressed soft tissues on the dorsal surface of the forearm. After that, I used Periosteal Massage on the periosteum of the right lateral epicondyle and cross fiber friction on the tendinous part of extensor digitorum muscle just at its insertion into the epicondyle. Both areas were exceptionally tender during treatment. I finished the session with Lymphatic Drainage for her legs and reapplied the KT for her workout tomorrow. 

 

Fifth Appointment: Wednesday 

          When the patient arrived she said, “I felt almost no pain at practice yesterday, and I’m feeling stronger in my shoulder and wrist. My serve is getting faster.” I again used TE Protocol, and there was a dramatic decrease in tenderness intensity during the Periosteal Massage on the epicondyle and cross fiber Friction on the tendon of the extensor digitorum. Muscle Resistance Tests for extensors caused no elbow pain and were, as the patient said, “pain-free, but a little sore, and nothing like before.” 

          We discussed corrective exercises based on her tennis training and following the National Academy of Sports Medicine (NASM) guidance. 

          As always with my patients, I followed up with several emails. Every time she replied that she was playing well with no pain and stronger serves. She referred many new patients to my clinic and wants to make follow-up appointments to help her with post-tournament recovery and to prevent future traumas and over-training.

 

About the Author

          Ben Keyes, has been a Licensed Massage Therapist working mostly in clinical settings over his 20-year career. He has worked in chiropractic offices, physical therapy, and acupuncture clinics.

          His interest in working in the healthcare part of the massage industry came from an experience of being diagnosed with bilateral Carpal Tunnel Syndrome while in massage school. It was reading a book about orthopedic assessments where he tested negative for CTS. Different assessments indicated Pronator Teres Syndrome. Moments after self-treatment and continued self-care over the next few days resolved his pain and restored his range of motion.

         Just a few months into massage school, Ben realized detailed evaluation and medical massage therapy are something that could help a lot of people. This one experience where evaluation determined a treatment approach set him on the path to learning about pathologies and anatomy through dissection seminars, evaluation from practitioners in various specialty fields, and amassing as many massage therapy approaches whose use can be indicated or ruled out through evaluation.

          Ben became licensed as a massage therapist by the State of Florida’s Department of Health in 2002. He is an active member of three major massage therapy associations. He is known locally as a low back pain specialist to the physicians who refer their patients, as well as for working with athletes seeking their highest level of ability in their sport. Opening his solo practice office in 2014 in Orlando, Florida, he has built his practice on physician referrals and runs a large sports massage team.

          When asked about his favorite thing about being a Licensed Massage Therapist, Ben said, “Receiving a phone call from a patient to let me know they canceled a surgery that was scheduled because Medical Massage was incorporated into their care is a highlight of my career and I get that joy dozens of times a year. That is 100% thanks to my instructors and those who went before them. I will forever be a student and look forward to helping educate others. Massage has allowed me to travel the world to work with incredible athletes, but the work I get to do in my community brings me joy every day.”


Category: Case Studies

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