Tennis Elbow

Symptoms

Pain on the outer part of elbow (lateral epicondyle).

Point tenderness over the lateral epicondyle  a prominent part of the bone on the outside of the elbow.

Gripping and movements of the wrist hurt, especially wrist extension and lifting movements.

Activities that use the muscles that extend the wrist (e.g. pouring a pitcher or gallon of milk, lifting with the palm down) are characteristically painful.

Morning stiffness.

Etiology

The strongest risk factor for lateral epicondylitis is age. The peak incidence is between 30 to 60 years of age. No difference in incidence between men and women or association between tennis elbow and the dominant hand has been demonstrated.

The pathophysiology of lateral epicondylitis is degenerative. Non-inflammatory, chronic degenerative changes of the origin of the extensor carpi radialis brevis (ECRB) muscle are identified in surgical pathology specimens. It is unclear if the pathology is affected by prior injection of corticosteroid.

Among tennis players, it is believed to be caused by the “repetitive nature of hitting thousands and thousands of tennis balls” which lead to tiny tears in the forearm tendon attachment at the elbow.

The extensor digiti minimi also has a small origin site medial to the elbow which can be affected by this condition. The muscle involves the extension of the fifth digit and some extension of the wrist allowing for adaption to nap or flick the wrist usually associated with a racquet swing. Most often, the extensor muscles become painful due to tendon breakdown from over-extension. Improper form or movement allows for power in a swing to rotate through and around the wrist creating a moment on that joint instead of the elbow joint or rotator cuff. This moment causes pressure to build impact forces to act on the tendon causing irritation and inflammation.

The following speculative rationale is offered by proponents[who?] of an overuse theory of etiology: The extensor carpi radialis brevis has a small origin and does transmit large forces through its tendon during repetitive grasping. It has also been implicated as being vulnerable during shearing stresses during all movements of the forearm.

While it is commonly stated that lateral epicondylitis is caused by repetitive microtrauma/overuse, this is a speculative etiological theory with limited scientific support that is likely overstated. Other speculative risk factors for lateral epicondylitis include taking up tennis later in life, unaccustomed strenuous activity, decreased reaction times and speed and repetitive eccentric muscle contractions (controlled lengthening of a muscle group).

Examination and tests

The diagnosis is made by clinical signs and symptoms, which are usually both discrete and characteristic. There should be point tenderness over the origin of the extensor carpi radialis brevis muscle from the lateral epicondyle (ECRB origin). There should also be pain with passive wrist flexion and also with resisted wrist extension (Cozen’s test), both tested with the elbow extended.

An easy at-home test can be performed to determine whether you have tennis elbow. Stand behind a chair, place your hands on top of the chair back with your palms down, and try to lift the chair up. If this causes pain on the outside of your elbow, the culprit is most likely tennis elbow.

MRI typically shows fluid in the ECRB origin. There may also be a defect in this tissue. The use of the word “tear” to refer to this defect can be misleading. The word “tear” implies injury and the need for repair both of which are probably inaccurate and inappropriate for this degenerative enthesopathy.

Depending on the severity and number of small tendon injuries that build up, the ECRB may not be able to fully heal. Nirschl defined four stages of lateral epicondylitis, showing the introduction of permanent damage beginning at Stage 2. The stages are:

Inflammatory changes that are reversible

Nonreversible pathologic changes to origin of the ECRB muscle

Rupture of ECRB muscle origin

Secondary changes such as fibrosis or calcification

Treatment

In general the evidence base for intervention measures is poor.

Non-specific palliative treatments include:

Non-steroidal anti-inflammatory drugs (NSAIDs): ibuprofen, naproxen or aspirin

Heat or ice

A counter-force brace or “tennis elbow strap” to reduce strain at the elbow epicondyle, to limit pain provocation and to protect against further damage.

Vibration therapy can be used for localized pain relief and inflammation with vibration therapy devices (Tenease) available for home use.

Rest is the tennis player’s treatment of choice when the pain first appears; the rest allows the tiny tears in the tendon attachment to heal. Tennis players treat more serious cases with ice (although the effectiveness of ice treatment has been challenged in clinical research), anti-inflammatory drugs, soft tissue massage, stretching exercises, and ultrasound therapy.

In recalcitrant cases surgery may be indicated. Many techniques have been described using open, percutaneous or arthroscopic approaches. Most techniques aim to release the strain on the extensor carpi radialis brevis muscle, remove degenerative tissue and promote healing.

Other treatments with limited scientific support include:

Acupuncture

Blood injection (possibly augmented by plateletpheresis)

Botulinum toxin

Extra-corporeal shock wave therapy (lithotriptor)

Heat therapy

Immobilization of the forearm and elbow using a splint for two to three weeks

Local injection of cortisone and a numbing medicine

Low level laser therapy

Occupational therapy, primarily for stretching and strengthening of the wrist extensor musculature.

Physical therapy

Platelet-rich plasma

Pulsed ultrasound to break up scar tissue, promote healing, and increase blood flow in the area

Sclerotherapy

Trigger point therapy

There are clinical trials addressing many of these proposed curative treatments, but the quality of these trials is generally poor.

One study has alleged that electrical stimulation combined with acupuncture is beneficial but evaluation studies are inconclusive.

One recent presentation at a scientific meeting described the Tyler Twist Protocol, a physical therapy intervention. Although the study has yet to be published to verify claims made in the newspaper.

Cortisone injections

In four clinical trials comparing corticosteroid injection to placebo (lidocaine) injection that show no effect of the steroids. Complications from repeated steroid injections include skin problems such as hypopigmentation and fat atrophy.

Exercises and stretches

There are several recommendations regarding prevention, treatment, and avoidance of recurrence that are largely speculative including:

Stretches and progressive strengthening exercises to prevent re-irritation of the tendon;

Progressive strengthening involving use of weights or elastic theraband to increase pain free grip strength and forearm strength;

Racquet sport players also are commonly advised to strengthen their shoulder rotator cuff, scapulothoracic and abdominal muscles by Physiotherapists to help reduce any overcompensation in the wrist extensors during gross shoulder and arm movements;

Soft tissue release or simply massage can help reduce the muscular tightness and reduce the tension on the tendons; and

Strapping of the forearm can help realign the muscle fibers and redistribute the load.

Use of a racket designed to dampen the effect of ball striking.

There is little evidence to support the value of these interventions for prevention, treatment, or avoidance of recurrence of lateral epicondylosis.

See also

Golfer’s elbow

Repetitive strain injury

Radial tunnel syndrome

References

^ Tennis elbow: even cricketers and housewives can get it, a Times of India article dated September 4, 2004

^ a b c What is tennis elbow? from the BBC Sport Academy website

^ Runge F. Zur Genese und Behandlung des Schreibekrampfes. Berliner Klin Wochenschr. 1873;10:245248.

^ Major HP. “Lawn-tennis elbow”. BMJ. 1883;2:557.

^ Kaminsky SB, Baker CL (December 2003). “Lateral epicondylitis of the elbow”. Techniques in Hand & Upper Extremity Surgery 7 (4): 17989. doi:10.1097/00130911-200312000-00009. PMID 16518219. 

^ a b c Boyer MI, Hastings H (1999). “Lateral tennis elbow: “Is there any science out there?”". Journal of Shoulder and Elbow Surgery 8 (5): 48191. doi:10.1016/S1058-2746(99)90081-2. PMID 10543604. 

^ Tennis elbow from the MedlinePlus Medical Encyclopedia

^ from WebMD’s emedicine

^ Bisset L, Paungmali A, Vicenzino B, Beller E (July 2005). “A systematic review and meta-analysis of clinical trials on physical interventions for lateral epicondylalgia”. British Journal of Sports Medicine 39 (7): 41122; discussion 41122. doi:10.1136/bjsm.2004.016170. PMID 15976161. 

^ Pain alleviation by vibratory stimulation, Lundeberg et al, The Journal of Pain, 1984

^ Manias P, Stasinopoulos D (January 2006). “A controlled clinical pilot trial to study the effectiveness of ice as a supplement to the exercise programme for the management of lateral elbow tendinopathy”. British Journal of Sports Medicine 40 (1): 815. doi:10.1136/bjsm.2005.020909. PMID 16371498. 

^ How to treat tennis elbow from the BBC Sport Academy website

^ Lo MY, Safran MR. Surgical treatment of lateral epicondylitis: a systematic review. Clin Orthop Relat Res 2007;463,98-106.

^ Mishra A, Pavelko T (November 2006). “Treatment of chronic elbow tendinosis with buffered platelet-rich plasma”. The American Journal of Sports Medicine 34 (11): 17748. doi:10.1177/0363546506288850. PMID 16735582. 

^ Cowan J, Lozano-Caldern S, Ring D (August 2007). “Quality of prospective controlled randomized trials. Analysis of trials of treatment for lateral epicondylitis as an example”. The Journal of Bone and Joint Surgery 89 (8): 16939. doi:10.2106/JBJS.F.00858. PMID 17671006. 

^ Jiang ZY, Li CD, Guo JH, Li JC, Gao L (November 2005). “[Controlled observation on electroacupuncture combined with cake-separated moxibustion for treatment of tennis elbow]” (in Chinese). Zhongguo Zhen Jiu 25 (11): 7634. PMID 16335198. 

^ New York Times article with video of the Tyler Twist Protocol.

^ Haines T, Stringer B (April 2007). “Corticosteroid injections or physiotherapy were not more effective than wait and see for tennis elbow at 1 year”. Evidence-based Medicine 12 (2): 39. doi:10.1136/ebm.12.2.39. PMID 17400631. 

^ Stasinopoulos D, Stasinopoulou K, Johnson MI (December 2005). “An exercise programme for the management of lateral elbow tendinopathy”. British Journal of Sports Medicine 39 (12): 9447. doi:10.1136/bjsm.2005.019836. PMID 16306504. 

Further reading

Wilson JJ, Best TM (September 2005). “Common overuse tendon problems: A review and recommendations for treatment”. American Family Physician 72 (5): 8118. PMID 16156339. http://www.aafp.org/afp/20050901/811.html. 

v  d  e

Soft tissue disorders / Rheumatism / Connective tissue arthropathy (M65-M79, 725-727)

Capsular

Synoviopathy

Synovitis/Tenosynovitis (Calcific tendinitis, Stenosing tenosynovitis, Trigger finger, DeQuervain’s syndrome)  Transient synovitis  Ganglion cyst

osteochondromatosis (Synovial osteochondromatosis)  Plica syndrome

villonodular synovitis (Giant cell tumor of the tendon sheath)

Bursopathy

Bursitis (Olecranon, Prepatellar, Trochanteric, Subacromial)  Synovial cyst (Baker’s cyst)

Noncapsular

Fasciopathy

Fasciitis: Plantar  Nodular  Necrotizing  Eosinophilic

Fibromatosis/contracture

Dupuytren’s contracture  Peyronie’s disease  Plantar fibromatosis  Aggressive fibromatosis  Knuckle pads

Tendinopathy/

Enthesopathy/Enthesitis

upper limb (Adhesive capsulitis of shoulder, Rotator cuff tear, Golfer’s elbow, Tennis elbow)

lower limb (Iliotibial band syndrome, Patellar tendinitis, Achilles tendinitis, Calcaneal spur, Metatarsalgia)  Bone spur

other/general: Tendinitis  Tendinosis

joint navs: anat, non-congenital arthropathies/deformities/dorsopathies/soft tissue arthropathy/congenital, eponymous signs, proc

muscle, DF+DRCT navs: anat/hist/physio, acquired myopathy/congenital myopathy/neoplasia, symptoms+signs/eponymous, proc

v  d  e

Inflammation

Acute

Plasma derived mediators

Bradykinin  complement (C3, C5a, MAC)  coagulation (Factor XII, Plasmin, Thrombin)

Cell derived mediators

preformed: Lysosome granules  vasoactive amines (Histamine, Serotonin)

synthesized on demand: cytokines (IFN-, IL-8, TNF-, IL-1)  eicosanoids (Leukotriene B4, Prostaglandins)  Nitric oxide  Kinins

Chronic

Macrophage  Epithelioid cell  Giant cell  Granuloma

Processes

Traditional: Rubor  Calor  Tumor  Dolor (pain)  Functio laesa

Modern: Acute-phase reaction/Fever  Vasodilation  Increased vascular permeability  Exudate  Leukocyte extravasation  Chemotaxis

Specific types

Nervous

CNS (Encephalitis, Myelitis)  Meningitis (Arachnoiditis)  PNS (Neuritis)  eye (Dacryoadenitis, Scleritis, Keratitis, Choroiditis, Retinitis, Chorioretinitis, Blepharitis, Conjunctivitis, Iritis, Uveitis)  ear (Otitis, Labyrinthitis, Mastoiditis)

Cardiovascular

Carditis (Endocarditis, Myocarditis, Pericarditis)  Vasculitis (Arteritis, Phlebitis, Capillaritis)

Respiratory

upper (Sinusitis, Rhinitis, Pharyngitis, Laryngitis)  lower (Tracheitis, Bronchitis, Bronchiolitis, Pneumonitis, Pleuritis)  Mediastinitis

Digestive

mouth (Stomatitis, Gingivitis, Gingivostomatitis, Glossitis, Tonsillitis, Sialadenitis/Parotitis, Cheilitis, Pulpitis, Gnathitis)  tract (Esophagitis, Gastritis, Gastroenteritis, Enteritis, Colitis, Enterocolitis, Duodenitis, Ileitis, Caecitis, Appendicitis, Proctitis)  accessory (Hepatitis, Cholangitis, Cholecystitis, Pancreatitis)  Peritonitis

Integumentary

Dermatitis (Folliculitis)  Cellulitis  Hidradenitis

Musculoskeletal

Arthritis  Dermatomyositis  soft tissue (Myositis, Synovitis/Tenosynovitis, Bursitis, Enthesitis, Fasciitis, Capsulitis, Epicondylitis, Tendinitis, Panniculitis)

Osteochondritis: Osteitis (Spondylitis, Periostitis)  Chondritis

Urinary

Nephritis (Glomerulonephritis, Pyelonephritis)  Ureteritis  Cystitis  Urethritis

Reproductive

female: Oophoritis  Salpingitis  Endometritis  Parametritis  Cervicitis  Vaginitis  Vulvitis  Mastitis

male: Orchitis  Epididymitis  Prostatitis  Balanitis  Balanoposthitis

pregnancy/newborn: Chorioamnionitis  Omphalitis

Endocrine

Insulitis  Hypophysitis  Thyroiditis  Parathyroiditis  Adrenalitis

Lymphatic

Lymphangitis  Lymphadenitis

Categories: Inflammations | Overuse injuries | Tennis terminology | Soft tissue disordersHidden categories: Portal:Tennis/Total | All articles with specifically-marked weasel-worded phrases | Articles with specifically-marked weasel-worded phrases from March 2009
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