Tennis Elbow

By Terry Zeigler, EdD, ATC 

Lateral elbow pain is one of the most common elbow problems for athletes participating in racquet sports. Although commonly referred to as “tennis elbow,” a number of medical names have surfaced in recent years to better define the physiology of the injury including lateral epicondylitis, lateral epicondylalgia, and extensor tendinopathy.

While experts disagree as to the exact definition of the problem, recent research has revealed promising treatment utilizing an inexpensive tool as well as eccentric exercises to reduce pain and get athletes back on to the court. Because there are physiological changes to the tendon, the term extensor tendinopathy will be used in this article.

What is tennis elbow or extensor tendinopathy?

A basic knowledge of muscle anatomy is important to understanding the causes of lateral elbow pain. Although the pain that the athletes are feeling is in and around the elbow, the muscles that are causing the elbow pain attach in the hand, cross the wrist and elbow, and insert on the lateral side of the distal humerus (lower portion of the arm near the elbow).

The muscles that are directly involved in causing the lateral elbow pain are the muscles involved in wrist extension. There are a group of small muscles that extend the wrist and originate on the lateral humerus just above the elbow. Overuse of the wrist either by sport or by profession can result in lateral elbow pain.

Initially, the response to the original injury may cause inflammation in and around the tendon resulting in point tenderness and pain with movement. However, if the athlete continues to practice/compete through pain, the condition can deteriorate resulting in abnormal changes within the tendon itself.

The actual pathology involves a degeneration of one of the wrist extensor tendons (extensor carpi radialis brevis or ECRB) just below its attachment to the humerus. This is thought to occur because this area has a poor blood supply. A poor blood supply in combination with excessive use can cause degenerative changes in soft tissue (Brukner, P. & Khan, K., 2002).

Overtime, the degenerative changes (changes in the tissue) can result in microtears and scarring within the tendon. The result is pain and discomfort anytime the athlete uses his/her wrist. The pain is exacerbated when a racquet is added to the hand because the long lever increases the amount of forces on the wrist and elbow.

Who gets extensor tendinopathy? 

In the sports world, athletes who compete in racquet sports are susceptible to extensor tendinopathies because of the added forces placed on the elbow from the racquet. Specific motions that aggravate pain in the lateral elbow are those that involve repeated wrist extension against resistance (backhand).

Athletes are not the only population that may be at risk for lateral elbow pain. Any activity that uses repetitive wrist extension can be a cause including occupational and recreational activities such as carpentry, sewing, knitting, and bricklaying.

The individuals with the highest incidence of extensor tendinopathy are tennis players older than 30 with a peak range between ages 35 and 50 (Bahr, R. & Maehlum, S., 2004) with both men and women equally affected by the condition.

Other athletes who may suffer from lateral elbow pain include golfers, throwers, swimmers, fencers, and baseball players. Although some of these athletes may also suffer from medial elbow pain, lateral elbow pain is significantly more common (5 – 10 times) (Bahr, R. & Maehlum, S., 2004).

What causes extensor tendinopathy? 

Sources generally site the reliance of the wrist and elbow rather than the use of the full body as a primary cause of lateral elbow pain in tennis players. If the arm is used as a single lever together with the racquet (elbow remains straight), then the body absorbs the forces of the ball rather than the elbow.

However, if the athlete’s footwork does not place the body in a position to utilize the arm as a single lever and the athlete swings the racquet using their elbow rather than their body, then all of the forces of the ball are absorbed by the lateral elbow. Leading with the elbow rather than using the full body to complete a backhand is not the only cause of extensor tendinopathy.

Other predisposing factors that may contribute to extensor tendinopathy include:

• Excessive forearm pronation when hitting a topspin forehand
• Excessive wrist flexion while serving
• Racquet type
• Grip size (too small or too large)
• String tension (too tight)

How is extensor tendinopathy diagnosed? 

An experienced sports medicine professional can diagnose extensor tendinopathy through the use of a thorough medical history, and a clinical evaluation including manual muscle tests and special tests designed to isolate extensor tendinopathy.

One of the more common tests for extensor tendinopathy is a lateral epicondylitis test. The practitioner stabilizes the forearm of the athlete on a table and places the athlete’s wrist in full flexion. While applying resistance to the back of the hand, have the athlete extend his/her wrist through the full range of motion. If this test reproduces the athlete’s pain in his/her lateral elbow, it is considered a positive test for extensor tendinopathy.

What is the treatment for extensor tendinopathy? 

A number of treatments have surfaced over the years to treat lateral elbow pain with some being more effective than others. A recent review of the literature revealed a variety of treatment options including:

• Iontophoresis (application of a medication through the skin using electrical stimulation modality)
• Phonophoresis (application of a medication through the skin using ultrasound)
• Extracorporeal shockwave therapy
• Corticosteroid injections
• Topical nitric oxide
• Massage therapy
• Counterforce bracing
• Stretching
• Strengthening

The basic principles for treating soft tissue injuries apply to treating extensor tendinopathy. Initially, the goal is to control pain and inflammation. This is typically controlled by rest, cryotherapy, and anti-inflammatory medication.

Once pain and inflammation are under control, the treatment goals are to enhance the healing process and to restore the mobility and flexibility in the soft tissues (muscles and tendons) and strengthen the weakened muscles.

More Information: Read about sports injury treatment using the P.R.I.C.E. principle – Protection, Rest, Icing, Compression, Elevation.

 

Exercise

A new exercise presented at the American Orthopaedic Society for Sports Medicine in 2009 holds promise for effectively treating extensor tendinopathy. The advantage of this new exercise over the traditional treatments listed above is that it can be done at home without the need of a sports medicine professional to apply the treatment.

Eccentric training is a proven effective treatment for tendonitis and for chronic lateral epicondylitis (Houglum, P., 2006). On this foundation, researchers from the Nicholas Institute of Sports Medicine and Athletic Trauma and Pro Sports Physical Therapy conducted a study looking at the effectiveness of a new eccentric wrist extensor exercise utilizing a Thera-Band Flexbar. 

Although the number of subjects was small in this study, the results were promising. The researchers concluded that the addition of an eccentric wrist extensor exercise to standard physical therapy significantly decreased pain and improved strength in the subjects in the eccentric training group over the subjects in the control group (Tyler, T., Nicholas, S., Thomas, G., & McHugh, M., 2009).

Both the control group and the eccentric training group received traditional therapy treatments including wrist extensor stretching, ultrasound, cross-friction massage, heat and ice. Additionally the control group performed traditional isotonic wrist strengthening exercises while the eccentric training group performed isolated eccentric wrist extensor strengthening exercises using the rubber bar.

The subjects in the eccentric training group performed three sets of 15 repetitions of the eccentric wrist extension exercises daily with the intensity increasing progressively throughout the study. Because there was such a large improvement in the eccentric training group over the standardized treatment group, the study was terminated early.

Recovery – Getting back to Sport

As the pain in the lateral elbow decreases (pain-free wrist extension and pain-free pronation and supination), the athlete can begin functional sport-specific training to prepare the elbow to return to sports.

If it was determined that the cause of the initial elbow injury was linked to poor mechanics, then a professional may need to be consulted at this point to assist in teaching the athlete proper mechanics and reduce the possibility of reoccurrence of elbow pain.

Assuming that the athlete’s mechanics are correct and the athlete’s racquet is the correct size, the athlete can begin returning to the court with some basic drills. Initially the drills should be low intensity and involve low repetitions so that the athlete can gradually increase the amount of forces on the elbow over time.

All basic skills should be included in the functional exercises including forehand, backhand, volleying, and serving. As low-intensity drills (beginning at 50%) are completed without pain, the intensity of ground strokes can gradually increase over time.

Because it has been reported that counterforce bracing may help reduce forces to the lateral elbow (Brukner, P. & Khan, K., 2002), the athlete may consider the use of a counterforce brace when returning to sport. However, the placement of the brace is important. Individuals tend to mistakenly place the brace directly over the painful area when in fact the correct site is about three to four inches below the elbow joint (depending on the size of the individual).

If the brace is applied, it should be applied snugly but not too tight. Any numbness or tingling into the hand may indicate that the brace has been applied too tight and needs to be loosened.

When Can I Return to Play? 

The athlete can return to sport when he/she has been released to return by his/her sports medicine professional and when he/she has pain-free range of motion and full strength of the wrist and elbow.

Find a Doctor who specializes in Tennis Elbow:

American Orthopedic Society for Sports Medicine
6300 North River Rd.
Suite 200
Rosemont, IL 60018
Toll-Free: (877) 321-3500
http://www.sportsmed.org/

American Academy of Orthopaedic Surgeons (AAOS)
6300 North River Rd.
Rosemont, IL 60018-4262
Toll-Free: (800) 346-2267
http://www.aaos.org/

American Physical Therapy Association
1111 North Fairfax St.
Alexandria, VA 22314-1488
Toll-Free: (800) 999-2782
http://www.apta.org/

National Athletic Trainers’ Association
2952 Stemmons Freeway
Dallas, TX 75247-6196
Phone: (214) 637-6282
http://www.nata.org/

 

References

  • Anderson, M., Parr, G. P. & Hall, S. (2009). Foundations of Athletic Training: Prevention, Assessment, and Management. (4th Ed.). Lippincott Williams & Wilkins: Baltimore, MD.
  • Bahr, R. & Maehlum, S. (2004). Clinical Guide to Sports Injuries. Human Kinetics: Champaign, IL.
  • Brukner, P. & Khan, K. (2002). Clinical Sports Medicine. (2nd Ed.). McGraw Hill: Australia.
  • Houglum, P. (2005). Therapeutic Exercise for Musculoskeletal Injuries. (2nd Ed.). Human Kinetics: Champaign, IL.
  • Tyler, T., Nicholas, S., Thomas, G. & McHugh, M. (2009). Addition of a Novel Eccentric Wrist Extensor Exercise to Standard Treatment for Chronic Lateral Epicondylitis: A Prospective Randomized Trial. Accessed on June 16, 2010 at http://www.sportsmed.org.

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