“I think it might be worse,” she said. “The problem might be spreading to other areas of my arm.”
My eyes widened as I tried to make sense of what Ms. M. was telling me. Ms. M. was a pianist who had first come to see me six days earlier with pain in her right lateral epicondyle. I had only seen her once, but three days after that first treatment, she sent me an email in which she was ecstatic at the results achieved. How could things have gone south just days since that massage?  
“Gosh, I’m a little stunned,” I admitted. “I thought your elbow was significantly improved after our session last week.”
“Well, it was better, but now I am feeling the pain here,” she said, pointing to her triceps muscle. “I don’t think I ever felt pain here before. Perhaps the problem is more widespread than I thought.”
“Before we began the work last week, you mentioned that the action of brushing your teeth was extremely painful. Were you able to brush your teeth with your right hand this week, or did you have to use your left hand again because of the pain?”
“Um, no. I have been brushing my teeth using my right hand for probably the last four days,” she said, giving me a puzzled look. “I kind of forgot how difficult that was for me.”
“Are you still taking as much medication for pain as you were before we worked last week?” I asked.
“No, I haven’t taken anything for the last few days,” she admitted.
“That’s good,” I said. “But, I am still a little confused as to how you see the problem as worse since two of the markers for improvement—teeth brushing and medication use—are significantly better.”
“I guess I am just concerned about this new area of pain in my arm surfacing now,” Ms. M. said.  
“May I ask how you would rate the pain, and maybe more importantly, how much does this new area of discomfort affect your daily life?”
“This pain seems to have a different quality than the one I first came in with. While the original pain was debilitating, this pain is a sensation of fatigue and a deep ache. As a pianist, I have also been practicing a lot more this week, getting ready to perform a new piece.”
“Who was the composer?” I inquired.  
“Franz Liszt,” she responded. (If you are at all familiar with piano literature, compositions by Liszt are massive works and physiologically challenging to play. Liszt had large hands and virtuoso technique; his pieces are often incredibly fast, powerful, and extremely demanding.)
Ms. M. demonstrated for me some of the difficult passages via “air piano” and the large chords and powerful pounding on the keys involved using lots of forceful elbow extension.
“May I tell you a story about one of my clients before we continue?” I asked. “I think you might find it helpful.
“I had seen this woman many times over the last few months; she had several very painful muscular issues due to a car accident. When I asked her how she was doing at her appointment last week, she complained of pain in her big toe. I probably gave her a look of confusion and concern. She, however, smiled and told me how delighted she was to have toe pain. Her point was that she, for many years, had low-grade pain in her big toe. After her car accident, multiple other areas of the body were of much greater concern to her nervous system. The toe pain was pushed far down the pain hierarchy. As she said, ‘In the world of pain, the loudest voice wins. If I am aware of my toe aching, I know I must be getting better.’
“I think she nailed it. Do you see how that translates to your own experience?”
“I think I do,” Ms. M. replied. “The intense elbow pain overshadowed anything coming from the triceps, which now has the louder voice. Turning down the volume of the original pain allowed me to hear messages coming from the triceps.”
“Absolutely,” I agreed. “The triceps discomfort was likely there before, but the Liszt composition placed an extreme demand on a muscle that was already somewhat compromised. The confluence of both factors is probably the reason it is speaking rather loudly to you right now.”
“That makes a lot of sense,” Ms. M. replied. “After you treat it today, I think there are two things I can do to help. First, I’ll change my practice routine to limit the stress on that area. I got the message; the triceps doesn’t need to yell to get my attention anymore.”
“And second?” I asked.
“I am going to ask my triceps to use an inside voice!” she replied.  

Douglas Nelson is the founder and principal instructor for Precision Neuromuscular Therapy Seminars, president of the 16-therapist clinic BodyWork Associates in Champaign, Illinois, and president-elect of the Massage Therapy Foundation. His clinic, seminars, and research endeavors explore the science behind this work. Visit www.nmtmidwest.com, or email him at doug@nmtmidwest.com.