Left elbow-joint, showing posterior and radial collateral ligaments. (Lateral epicondyle visible at center.)
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Any activity, including playing tennis, which involves the repetitive use of the extensor muscles of the forearm can cause acute or chronic tendonitis of the tendinous insertion of these muscles at the lateral epicondyle of the elbow. The condition is common in carpenters and other laborers who swing a hammer or other tool with the forearm.
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Signs and symptoms
- Pain on the outer part of the elbow (lateral epicondyle)
- Point tenderness over the lateral epicondyle—a prominent part of the bone on the outside of the elbow
- Pain from gripping and movements of the wrist, especially wrist extension and lifting movements
- Pain from activities that use the muscles that extend the wrist (e.g. pouring a container of liquid, lifting with the palm down, sweeping, especially where wrist movement is required)
Symptoms associated with tennis elbow include, but are not limited to: radiating pain from the outside of the elbow to the forearmand wrist, pain during extension of wrist, weakness of the forearm, a painful grip while shaking hands or torquing adoorknob, and not being able to hold relatively heavy items in the hand. The pain is similar to the condition known as golfer's elbow, but the latter occurs at the medial side of the elbow.
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Causes
Tennis elbow is a type of repetitive strain injury, resulting from tendon overuse and failed healing of the tendon. In addition, the extensor carpi radialis brevis muscle plays a key role.
Early experiments suggested that tennis elbow was primarily caused by overexertion. However, studies show that trauma such as direct blows to the epicondyle, a sudden forceful pull, or forceful extension cause more than half of these injuries. It has also been known that incorrectly playing tennis may cause early stages of tennis elbow as shock is received when mishitting the ball.
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Prevention
Another factor of tennis elbow injury is experience and ability. The proportion of players who reported a history of tennis elbow had an increased number of playing years. As for ability, poor technique increases the chance for injury much like any sport. Therefore, an individual must learn proper technique for all aspects of their sport. The competitive level of the athlete also affects the incidence of tennis elbow. Class A and B players had a significantly higher rate of tennis elbow occurrence compared to class C and novice players. However, an opposite, but not statistically significant, trend is observed for the recurrence of previous cases, with an increasingly higher rate as ability level decreases.
Other ways to prevent tennis elbow:
- Decrease the amount of playing time if already injured or feeling pain in outside part of the elbow.
- Stay in overall good physical shape.
- Strengthen the muscles of the forearm: (pronator quadratus, pronator teres, and supinator muscle)—the upper arm: (biceps, triceps)—and the shoulder (deltoid muscle) and upper back (trapezius). Increased muscular strength increases stability of joints such as the elbow.
- Like other sports, use equipment appropriate to your ability, body size, and muscular strength.
- Avoid any repetitive lifting or pulling of heavy objects (especially over your head)
Vibration dampeners (otherwise known as "gummies") are not believed to be a reliable preventative measure. Rather, proper weight distribution in the racket is thought to be a more viable option in negating shock.
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Diagnosis
To diagnose tennis elbow, the physician performs a battery of tests in which he places pressure on the affected area while asking the patient to move the elbow, wrist, and fingers. X-rays can confirm and distinguish possibilities of existing causes of pain that are unrelated to tennis elbow, such as fracture or arthritis. Medical ultrasonography andmagnetic resonance imaging (MRI) are other valuable tools for diagnosis but are frequently avoided due to the high cost. MRI screening can confirm excess fluid and swelling in the affected region in the elbow, such as the connecting point between the forearm bone and the extensor carpi radialis brevis.
Diagnosis is made by clinical signs and symptoms that are discrete and characteristic. With the elbow fully extended, the patient feels points of tenderness over the affected point on the elbow—which is the origin of the extensor carpi radialis brevis muscle from the lateral epicondyle (extensor carpi radialis brevis origin). There is also pain with passive wristflexion and resistive wrist extension (Cozen's test). Resisted middle finger extension might indicate the involvement of Extensor Digitorum also. These tests shall be used to measure the prognosis of the condition.
Depending upon severity and quantity of multiple tendon injuries that have built up, the extensor carpi radialis brevis may not be fully healed by conservative treatment. Nirschl defines four stages of lateral epicondylitis, showing the introduction of permanent damage beginning at Stage 2.
- Inflammatory changes that are reversible
- Nonreversible pathologic changes to origin of the extensor carpi radialis brevis muscle
- Rupture of ECRB muscle origin
- Secondary changes such as fibrosis or calcification.
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Treatment
Tennis elbow left untreated can lead to chronic pain that degrades quality of daily living.
Physical
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 and other exercise measures.
One way to help treat minor cases of tennis elbow is to simply relax the affected arm. The rest will allow the stress and tightness within the forearm to slowly relax and eventually have the arm in working condition once again in a day or two, depending on the case.
Evidence suggests that eccentric exercise using a rubber bar is highly effective at eliminating pain and increasing strength. The exercise involves grasping a rubber bar, twisting it, then slowly untwisting it.
Moderate evidence exists demonstrating that joint manipulation directed at the elbow and wrist and spinal manipulation directed at the cervical and thoracic spinal regions results in clinical changes to pain and function. There is also moderate evidence for short-term and mid-term effectiveness of cervical and thoracic spine manipulation as an add-on therapy to concentric and eccentric stretching plus mobilisation of wrist and forearm. Although not yet conclusive, the short-term analgesic effect of manipulation techniques may allow more vigorous stretching and strengthening exercises, resulting in a better and faster recovery process of the affected tendon in lateral epicondylitis.
Low level laser therapy, administered at specific doses and wavelengths directly to the lateral elbow tendon insertions, offers short-term pain relief and less disability in tennis elbow, both alone and in conjunction with an exercise regimen. Of late, dry needling has been gaining popularity in various types of tendinopathies and pain of muscular origin. Even in lateral epicondylitis, dry needling is widely employed by many physical therapists across the world. It is believed that dry needling would cause a tiny local injury in order to bring about various desirable growth factors in the vicinity. Dry needling is also aimed at eliciting local twitch response (LTR) in the extensor muscles, as in some cases of tennis elbow the extensor muscles of the forearm would harbor trigger points, which itself could be a major source of pain.
Orthotic devices
Orthosis is a device externally used on the limb to improve the function or reduce the pain. Orthotics are useful therapeutic interventions for initial therapy of tennis elbow. There are two main types of orthoses prescribed for this problem: counterforce elbow orthoses and wrist extension orthoses.
Counterforce orthosis has a circumferential structure surrounding the arm. This orthosis usually has a strap which applies a binding force over the origin of the wrist extensors. The applied force by orthosis reduces the elongation within the musculotendinious fibers. Wrist extensor orthosis maintains the wrist in the slight extension. This position reduces the overloading strain at the lesion area.
Studies indicated both type of orthoses improve the hand function and reduce the pain in people with tennis elbow.
Medication
Although anti-inflammatories are a commonly prescribed treatment for tennis elbow, the evidence for their effect is usually anecdotal with only limited studies showing a benefit. A systematic review found that topical non-steroidal anti-inflammatory drugs (NSAIDs) may improve pain in the short term (up to 4 weeks) but was unable to draw firm conclusions due to methodological issues. Evidence for oral NSAIDs is mixed.
Evidence is poor for an improvement from injections of any type, be it corticosteroids, botulinum toxin, prolotherapy or other substances. Corticosteroid injection may be effective in the short term however are of little benefit after a year, compared to a wait-and-see approach. Complications from repeated steroid injections include skin problems such as hypopigmentation and fat atrophy leading to indentation of the skin around the injection site. Botulinum toxin type A to paralyze the forearm extensor muscles in those with chronic tennis elbow that has not improved with conservative measures may be reasonable.
Surgery
In recalcitrant cases, surgery may be an option. Surgical methods include:
- Lengthening, release or debridement of the origin of the extrinsic extensor muscles of the hand at the lateral epicondyle
- Rotation of the anconeus muscle
- Denervation of the lateral epicondyle
- Decompression of the posterior interosseous nerve
Surgical techniques for lateral epicondylitis can be done by open surgery, percutaneous surgery or arthroscopic surgery, with no evidence that any particular type is better or worse than another.
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Epidemiology
In tennis players, about 39.7% have reported current or previous problems with their elbow. Less than one quarter (24%) of these athletes under the age of 50 reported that the tennis elbow symptoms were "severe" and "disabling," while 42% were over the age of 50. More women (36%) than men (24%) considered their symptoms severe and disabling. Tennis elbow is more prevalent in individuals over 40, where there is about a four-fold increase among men and two-fold increase among women. Tennis elbow equally affects both sexes and, although men have a marginally higher overall prevalence rate as compared to women, this is not consistent within each age group, nor is it a statistically significant difference.
Playing time is a factor in tennis elbow occurrences. However, increased incidence with increased playing time is statistically significant only for respondents under 40. Individuals over 40 who played over two hours had a two-fold increase in chance of injury. Those under 40 had a 3.5 times increase compared to those who played less than two hours per day.
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