The presence of elbow pain can have a tremendous impact on our lives. When

elbow pain develops it often results in the restricted use of our arm and hand both at work

and in our free time, affecting our enjoyment and quality of life. Seemingly simple

activities such as lifting, grasping, and typing can seem like a monumental task and can

seem like a monumental task and can greatly aggravate the condition. Those who have

been unfortunate enough to suffer these types of symptoms have often been subjected to

wearing an elbow brace and changing their daily routines in an attempt to take the strain

off the painful elbow with the hope of healing the condition. Others have sought various

forms of treatment ranging from medication, ultrasound, electrical stimulation, stretches,

and exercises, only to be continually frustrated and disappointed at their continued pain

and limited use of their arm.

Fortunately, a new treatment technique known as Active Release Technique

(ART) is proving to be a very effective method to combat elbow problems and help get

elbow pain sufferers back to their normal daily activities. But before we talk about how

ART works so effectively we first need to understand how the elbow becomes injured

in the first place.

To fully understand how elbow pain develops we need to first understand how the

muscles of the elbow are associated with the hand. This is important because the large

majority of elbow problems are associated with strain occurring at the wrist and hand, not

just the elbow itself.

The hand is a very complicated area and as such there are a very large number of

muscles that are associated with the hand and wrist. The majority of these muscles,

especially the stronger muscles, actually run all the way from the hand, up the forearm

and attach at the elbow. You can easily test this yourself by squeezing your forearm and

firmly opening and closing your hand. You will feel the muscles in the forearm contract

and relax as you open and close the hand.

It is important to realize that even though it is a small area, there are many

different muscles that attach at the elbow and travel down the hand. These muscles are

arranged in layers, and each muscle within each layer has a different job, or function. For

example, some of the muscles in the most superficial layer, that is the layer right under

the skin, travel down and attach to the wrist. When they contract they act to flex and

extend the wrist. Some of the muscles in the middle and deeper layers attach all the way

into the fingers and when they contract they move the fingers, such as when making a fist

or picking up objects. These deeper muscles that move the fingers may have many

separate tendons that go to each individual finger. This makes it possible to move one

finger by itself, and enables us to carry out tasks requiring fine motor skills such as

typing, buttoning a shirt, or playing the guitar.

As was previously mentioned, all of these muscles attach up at the elbow. If you

were to stand with the arm straight at your side and the palm facing forward, you will be

able to feel a bony prominence at the elbow on the side closest to the body. This is called

the medial epicondyle. The muscles on the front of the forearm are collectively called the

flexor muscles. Although there are many different muscles and many different layers of

muscles, the vast majority of these muscles attach to medial epicondyle through what is

known as the common flexor tendon. There is a similar situation on the back of the

forearm as well. The muscles on the back of the arm are known as the extensor muscles.

The various extensor muscles attach to the lateral epicondyle, which is the body

prominence on the outside of the elbow opposite the medial epicondyle.

Within our daily routines we use our hands a great deal. As a result there is a

tremendous amount of strain placed on the muscles of the hand and wrist- and remember,

these muscles attach at the elbow. Every time you pick up an object, swing a golf club, or

carry a bag of groceries the muscles of the hand and wrist must be active. Even an

activity such as typing puts a tremendous amount of strain through low level repetitive

contraction on these flexor and extensor muscle groups, and also at the elbow by way of

the common flexor and extensor tendons.

In addition to high levels of muscle activity that is inherent in normal daily

activities, many factors also place additional strain and work load on these muscles. For

example, repetitive use with certain sports or occupations, joint tightness at the wrist,

elbow, or shoulder, muscles imbalances, or previous injuries that may not have been fully

treated or rehabilitated can further strain the muscles of the elbow.

Over time this strain ca develop into what is known as micro-trauma. Simply

stated, micro-trauma is very small-scale muscle damage that occurs in the muscles and

ligaments in response to small levels of stain Initially this micro-trauma is not painful,

but may be perceived as a mild ache or tightness in the muscles, or at the medial or lateral

epicondyles. Although it is only small, this damage still needs to be repaired. The body

responds to micro-trauma by laying down small amounts of scar tissue to repair the

injured tissue.

Unfortunately over time this scar tissue will build up and accumulate into what

we call adhesions. As these adhesions form they start to affect the normal health and

function of the muscles. In fact, they will often lead to pain, tightness, lack of flexibility,

muscle weakness, compromised muscle endurance, restricted joint motion and altered

biomechanics, and diminished blood flow.

As the muscles of the forearm become strained they also become very tight, and

the common tendon with which the muscles attach at the elbow begins to pull away from

its attachment site. This leads to pain and irritation at the area of the epicondyle. These

are how common elbow conditions such as medial epicondylitis, and lateral

epicondylitis- more commonly known as golfer’s elbow and tennis elbow- develop.

In addition to causing tightness, these adhesions are also very “sticky”, and affect

the ability of the muscles to stretch, contract, and slide over one another. Recall that there

are several layers of muscles in the forearm, and that each of these muscles has different

functions, and therefore contract at different times. For this process to occur correctly the

muscles need to be able to glide freely on one another. As adhesions develop they will

cause the individual muscles and various layers to stick on each other and prevent this

normal tissue gliding. When the muscles lose the ability to slide contraction of one

muscle will cause a pull and tension on all of the muscles even when the muscle is not

being used. This in turn will cause further strain to the region, and more strain on the

muscles as well as the epicondyle.

Another common development is that the accumulation of scar tissue adhesions

can affect the nerves in the region of the elbow and forearm. This occurs because

between the layers of muscles there are nerves that run all the way from the neck, down

the arm, past the elbow and forearm, and into the hand. Just as the muscles need to be

able to slide on each other, the nerves also need to be able to glide freely between the

layers of muscles. In many cases the accumulation of scar tissue can cause the nerves to

become “stuck” to the surrounding muscles. Instead of the nerve easily gilding between

the muscles it becomes stretched and irritated and can lead to other types of elbow and

lower arm pain. When the nerve becomes entrapped, in addition to pain, other symptoms

such as numbness, tingling, and weakness are often present. This is what commonly

happens in elbow conditions such as Ulnar Nerve Syndrome, Interosseous Nerve

Syndrome, or Radial Nerve Syndrome.

Treatment Perspectives

In an attempt to relieve elbow pain, a variety of treatment methods are used, either

on their own, or in combination with other methods. Some of the more common

approaches include anti-inflammatory medications, rest, ice, elbow splints or braces,

ultrasound (US), muscles stimulation (E-Stim), stretching, and exercise. Unfortunately

most of these traditional techniques generally require a long period of time before they

provide any significant relief, and in many cases provide only temporary relief from

symptoms instead of fixing the underlying cause of the problem.

The main reason that these approaches are often ineffective is that they fail to

address the underlying scar tissue adhesions that develop within the muscles and

surrounding soft tissues. It is these adhesions that are binding tissues together, restricting

the normal sliding of the tissues, and potentially entrapping the surrounding nerves at the

elbow and forearm.

Passive approaches such as medications, rest, ice, and steroid injections all focus

on symptomatic relief and do nothing to address the muscle restrictions and dysfunction.

More active approaches such as stretching and exercises are often needed for full strength

and function of the muscles; however, they themselves do not treat the underlying

adhesions. In fact, without first addressing the scar tissue adhesions, stretches and

exercises are often less effective and much slower to produce relief or recovery from the

elbow condition.

ART stands for Active Release Techniques. It is a new and highly successful

hands-on treatment method to address the problems in the soft tissues of the body,

including the muscles, ligaments, fascia, and nerves. ART treatment is highly

successful in dealing with elbow conditions because it is specifically designed to locate

and treat scar tissue adhesions that accumulate in the muscles and surrounding soft

tissues. By locating and treating the soft-tissue adhesions with ART, it allows the

practitioner to, 1) break up restrictive adhesions, 2) reinstate normal tissue flexibility and

movement, and 3) more completely restore flexibility, balance, and stability to the injured

area and to the entire kinetic chain.

You can think of ART treatment as a type of active massage. The practitioner

will first shorten the muscle, tendon, or ligament, and then apply a very specific pressure

with their hands as you actively stretch and lengthen the tissues. As the tissue lengthens

the practitioner is able to assess the texture and tension of the muscle to determine if the

muscle is healthy or contains scar tissue that needs further treatment. When scar tissue

adhesions are felt the amount and direction of tension can be modified to treat the

problematic area. In this sense, each treatment is also an assessment of the health of the

area as we are able to feel specifically where the problem is occurring.

An additional benefit of ART is it allows us to further assess and correct

problems not only at the site itself, but also in other areas of the kinetic chain, which are

associated with movement compensations and are often contributing factors to the

problem. This ensures that all the soft tissues that have become dysfunctional and are

contributing to the specific injury addressed, even if they have not yet all developed pain.

One of the best things about ART is how fast it can get results. In our

experience, the majority of elbow injuries respond very well to ART treatment,

especially when combined with the appropriate home stretching exercises. Although each

case is unique and there are several factors that will determine the length of time required

to fully resolve each condition, we usually find a significant improvement can be gained

in just 4-6 treatments. These results are the main reason that many elite athletes and

professional sports teams have ART practitioners on staff, and why ART is an

integral part of the Ironman triathlon series.

To book an appointment to see if ART will be able to help with your elbow

injury, simply call our office at 248-477- 2100.