Overview

Tennis elbow, or lateral epicondylitis, is a common overuse syndrome that affects the tendons on the outside of the elbow, causing pain and discomfort.^1,2,4 While it is most often associated with tennis players, it can affect anybody who engages in repetitive wrist and arm motion, such as painters, carpenters, and office workers.^1,2,4 This condition is characterised by inflammation and pain and has a severe effect on everyday activities and overall quality of life. This article discusses complementary therapies like acupuncture and massage as a means of relieving tennis elbow. Although traditional treatments, as anti-inflammatory drugs, steroid injections, and physical therapy, are widespread, some patients pursue complementary treatment in the form of acupuncture^1,2,4,5 and massage to help eliminate pain and hasten healing. Usually treated through physical therapy and anti-inflammatory medication, alternative therapies are becoming increasingly popular for their potential to reduce symptoms and stimulate healing.^1,2,4,5 This article discusses these alternative treatments, their effectiveness, and the aspects to consider when seeking symptom relief.

Understanding tennis elbow

What is tennis elbow?

Tennis elbow is inflammation or microtears ³ of the tendons attached to the lateral epicondyle of the humerus.^1,2,4,5,6 Despite being referred to as “tennis elbow,” it is not reserved for tennis players alone.^1,3,4,6 Any individual who engages in repetitive wrist and arm movement may develop this condition, as this causes strain in the extensor carpi radialis brevis muscle.^1,3,5

Causes and risk factors

There are several causes and risk factors which can result in lateral epicondylitis.^1,2,5 Some common risk factors include:

• Repetitive motion: Playing racquet sports, clipping hedges, extensive use of hammers, drills or screwdrivers, painting, and activities that entail excess repetitive squeezing or gripping, as well as intense, strenuous misuse of the forearm muscles and tendons^1,3,6
• Incorrect sporting techniques: Poor backhand strokes, weak shoulders and wrists, or a too tightly strung or too-short tennis racket. Hitting the ball off-centre or playing with heavy, wet balls can also cause it^3,6
• Occupational and leisure activities: Ergonomic strains for driving, other work tasks, and recreational activities⁶ Occupations that may be impacted include butchers, musicians, dentists, auto workers and carpenters^4,6

Symptoms and diagnosis

In the initial stage, symptoms can include pain, burning sensation, or an ache in the outer forearm and elbow.^1,2,3,5 However, these symptoms may vary between individuals, as follows:

• Pain that gets worse with time, even at rest^4,6
• Setting your arm and hand palm down on a surface and trying to raise your hand against resistance may cause pain^3,6
• Attempting to raise and hold little things, such as a coffee cup, can also cause pain³
• A weak grasp
• Prolonged discomfort and stiffness⁶
• Soreness in the forearm muscles^3,6
• When clutching or gripping anything, elbow discomfort gets worse⁶

A medical practitioner can diagnose it by asking you about your daily activities and past injuries,³ but in certain cases, further tests (X-ray, MRI, EMG) may be required. A healthcare provider can understand if these symptoms are related to other health conditions.

Acupuncture for tennis elbow

Overview of acupuncture and its principles

Acupuncture is an ancient Chinese medicinal practice^2,4 that has been used for over 3000 years. By inserting thin needles into specific bodily locations (acupoints), this technique encourages healing and balance,⁷ thereby enhancing energy flow and body harmony. Traditional Chinese Medicine (TCM) propounds that the body's vital energy, or Qi, moves along meridians or channels.^1,2,4 A lack of harmony in the flow of energy is purported to lead to disease and pain. Acupuncture aims to remove obstructions in Qi and stimulate the body's natural recuperative abilities.¹

Modern scientific research suggests that acupuncture works by stimulating muscles, nerves, and connective tissues, which enhances the availability of painkillers such as endorphins and improves blood flow.^1,4 For tennis elbow, acupoints are usually selected along the arm, elbow, and neck to target pain relief and improve circulation in the affected region.^1,2,4,5

How acupuncture helps relieve pain and inflammation

Acupuncture is believed to activate the nervous system,⁴ which releases endorphins and causes natural pain-relief pathways. It helps control inflammatory responses and improves blood flow to the affected tissue, promoting healing.^2,4 Acupuncture also relaxes muscles and reduces muscle tension, thus helping in pain relief. When acupuncture needles are placed in the forearm muscles, they break up scar tissue and aid in muscle relaxation, thus significantly lowering pain. Furthermore, electrical stimulation or other physical therapy modalities can be added to enhance pain relief.^1,2

Scientific evidence supporting acupuncture for tennis elbow

One article in The Journal of Pain Research found that acupuncture reduced pain and enhanced function in lateral epicondylitis patients. ⁵ The efficacy of acupuncture for tennis elbow has been confirmed by scientific research. A meta-analysis by Xu et al⁵ investigated ten randomised controlled trials, with 796 individuals. Their data revealed that, in comparison to placebo treatments and conventional medical procedures, acupuncture significantly improved pain levels and overall clinical outcomes. In these trials, acupuncture was more effective for treating lateral epicondylitis than medication, blocking therapy, or sham acupuncture.

According to a study by Zhang et al, acupuncture provided superior short-term relief compared to NSAIDs and corticosteroid injections.⁵ The authors noted its capacity to deliver long-lasting pain and function gains, as well as its negligible adverse effects.

Acupuncture is now part of the tennis elbow therapy options offered by the Royal Berkshire NHS Foundation Trust in the United Kingdom.⁶ This illustrates how acupuncture is becoming more widely accepted in conventional medicine.

Potential risks and considerations

While acupuncture is safe, side effects may include minor bleeding, ¹ bruising, and infection if improperly performed. To guarantee correct technique and cleanliness, one must receive treatment from a registered acupuncturist. Patients with bleeding disorders or taking blood-thinning medication should consult their doctor before undergoing acupuncture.

Massage therapy for tennis elbow

Types of massage therapy beneficial for tennis elbow

An alternative promising therapy for managing tennis elbow is massage.^7,8 It seeks to improve circulation, ease tense muscles, and drain lymphatic vessels.⁸

A variety of massage techniques can effectively relieve the symptoms of lateral epicondylitis. These include myofascial release, which aids in reducing tension and enhancing flexibility; deep transverse friction massage (DTFM);^7,8 and deep tissue massage, which targets deeper layers of muscle and fascia. The deep transverse friction massage technique involves providing massage to the tendons and muscles using the tips of one or two fingers.⁷ To improve tendon healing, DTFM applies pressure perpendicular to the path of the tendon fibres. This is done to break up scar tissue, realign collagen fibres, and increase fibroblastic activity.⁷ 

How massage facilitates healing

It brings greater blood supply to the injured tendons, enhances lymphatic drainage, and supplies oxygen. It relaxes adhesions and scarring caused by inflammation, which is responsible for stiffness and pain.^7,8 Additionally, massage decreases cortisol, while increasing serotonin and dopamine, contributing to relaxation, as well as pain relief.

Studies and clinical evidence on massage for tennis elbow

A study in The Journal of Orthopaedic & Sports Physical Therapy shows that patients who received deep tissue massage experienced notable pain reduction and improved grip strength compared to those who received conventional treatment.⁷ The Royal Berkshire NHS Foundation Trust's clinical guidelines support massage as a helpful technique in the larger physiotherapy treatment of tennis elbow.⁶ Research supports this practice, as examined data demonstrates that patients' grip strength and discomfort were much enhanced by soft tissue mobilisation.⁴

Furthermore, a study in the e-Journal of Clinical Medicine showed that combining massage therapy and rehabilitative exercise reduced pain and improved functional ability more than exercise alone.⁸ This synergy implies that massage might improve the outcomes of traditional treatment regimens, especially when the illness has persisted for a long time. 

Precautions and contraindications

Patients with acute inflammation or severe pain should not be given deep tissue massage because this can aggravate it. Fractured, infected, or cut areas in the affected region should not be given massage. Patients with circulatory disorders such as deep vein thrombosis or varicose veins must consult a medical practitioner before being given massage therapy.

Acupuncture vs. massage

Both relieve pain and promote healing, but they do so through different mechanisms:

• Acupuncture: shows the biggest impact on pain perception.^4,7 According to certain research, electroacupuncture - acupuncture combined with electrical stimulation - is especially beneficial^1,2,5,8
• Massage therapy: Applying deep transverse friction massage to muscles and tendons aims to increase blood flow within the tissue.⁷ According to one source, lateral epicondylitis can be treated with deep transverse friction massage^7,8

What to choose?

Acupuncture is helpful for inflammation, nerve sensitivity, or systemic symptoms. It stimulates the neurological system to release endorphins and modify pain pathways, providing notable temporary alleviation, occasionally surpassing traditional therapies like corticosteroid injections or NSAIDs in terms of effectiveness and fewer adverse effects.^2,5 It is also generally safe and minimally invasive when done by qualified specialists, which makes it a good option for individuals looking for systemic pain relief without the use of drugs. On the other hand, people who have myofascial trigger points, localised tendon thickening, or tight muscles benefit most from massage therapy. To promote tissue regeneration and mobility, techniques including deep tissue massage and deep transverse friction massage (DTFM) help break down adhesions, increase circulation, and realign collagen fibres within injured tendons.⁷ Additionally, massage can be used as a supplemental treatment in addition to rehabilitation activities, making it perfect for patients who prefer hands-on therapy. Together, massage and exercise therapy result in greater functional improvements than exercise alone.⁸

Combining both therapies

By addressing systemic and local sources of pain and dysfunction, acupuncture and massage may work together to produce positive effects. Acupuncture treats inflammatory pathways and neurochemical imbalances, whereas massage directly enhances tissue mobility and quality. Integrated treatment programs that combine the two approaches show quicker and longer-lasting results.^1,8 In cases of chronic or recurring tennis elbow, where both tendon degradation and central sensitisation may be present, this dual approach is significantly helpful.

Summary

Tennis elbow is a painful condition that can seriously impact daily life. Although conventional treatments remain useful, alternative forms of therapy like acupuncture and massage provide effective, non-surgical means for healing and pain relief. Acupuncture can stimulate the nervous system and reduce inflammation, while massage techniques relieve muscle tension and improve circulation. The choice between these treatments depends on several factors, and for most individuals, a combination will work best. Consultation with a health care provider before starting any alternative treatment will ensure safety and maximise benefits. Incorporating these treatments with stretching, ergonomic adjustments, and self-management, individuals afflicted with tennis elbow can experience long-term relief and improved functionality.