ACC Sports Sciences Feature: Tennis Elbow
Jeff Strahm, ATC-L
Lateral epicondylitis, otherwise known as Tennis Elbow, is a common malady of activities requiring use of the wrist, elbow and forearm. While typically not a career ending condition, Tennis Elbow can severely limit sport participation and day-to-day physical activities. Fortunately, this condition is relatively easily diagnosed and treated.
The lateral epicondyle is located on the outside or lateral aspect of the upper arm bone (humerus) at the level of the elbow. It is a boney prominence that is often easily seen and certainly easily felt. This part of the humerus is the origin of several muscles which serve to move the wrist and forearm. Specifically, the muscles serve to extend the wrist and fingers and turn the forearm so the palm is facing up (supination). In the sport of tennis, these muscles are essential in racket stabilization, racket rotation, and the backhand stroke.
Lateral epicondylitis is essentially inflammation of the origin of those important muscles. The cause of this inflammation is usually multi-factorial, but most often include overuse, poor conditioning, poor technique, and a change in technique or equipment. The stress which occurs at the origin of the muscles causes microscopic tears in the tissue. The body responds in attempt to heal the area with inflammation. This inflammation phase of healing will often result in pain, tenderness, swelling, and/or increased warmth. Specifically, people with tennis elbow commonly complain of pain with turning door knobs, opening jars, lifting a heavy bag, or even just turning the ignition in their car. Medical providers, such as physicians or athletic trainers, who evaluate someone with this problem, will typically find pain with pushing on the outside aspect of the affected elbow as well as pain at the same location with resisted wrist extension (cocking hand back), resisted supination of forearm, and resisted extension of the middle finger.
While inflammation is the body's means of healing damaged tissue, this can create a chronic, recurring problem if not properly treated. Treatment may be done with the help of an athletic trainer, physical therapist, or physician; or it may be done by the person affected on his or her own. Treatment always begins with evaluating the possible causes and trying to modify the activity that caused the symptoms.
For example, beginners often use incorrect technique during the backhand stroke by hyper-extending the wrist in attempt to gain more power while more advanced players will often flick the wrist during a backhand stroke to put topspin on the ball. In addition to technique, too much tension on the racquet strings, a grip size that is too small, and hitting a heavy or wet ball can all play a role in the development of lateral epicondylitis.
Someone who has recently changed his back hand technique or grip prior to developing symptoms would need to either return to the prior technique or grip or allow for time to adjust to the change prior to intense play. Additionally, rest is nearly always required to allow for complete healing of inflammation and resolution of symptoms. This may be as simple as cutting back on number of backhand strokes in practice. It could, however, be as significant as discontinuing practice and play for a period of time. The amount of rest required is directly proportional to the severity of symptoms and how the condition responds to treatment.
Another major component of treatment is rehabilitation by stretching and exercising. Improving flexibility and strength of the muscles involved allow for healing of tendons and muscles without loss of function and helps prevent recurrence once the person returns to play. The progression of exercises to return to play should be monitored very carefully. The patient should maintain flexibility with stretching exercises while incorporating various strengthening exercises. The progression of exercises may include isometrics, free weights, eccentrics, plyometrics, functional activities, and finally sport-specific activities. Progressing too rapidly through these exercises or returning to play too soon may cause a relapse in recovery. This underscores the value of having a sports medicine professional monitoring the rehabilitation.
There are several other treatment options for lateral epicondylitis. Ice is an important part of treatment as this helps control inflammation. Non-steroidal anti-inflammatory Drugs (NSAIDs), such as ibuprofen and naproxen, are very commonly used to help control inflammation and reduce pain. While evidence for there effectiveness is controversial, they are still typically recommended as part of treatment.
Tennis elbow braces are easy to obtain at most drug and sporting goods stores and claim to improve symptoms. Their purpose is to alter the forces of the muscles in order to take pressure/traction off the lateral epicondyle origin. There are some studies showing short term benefits in daily function with a brace. The brace alone, however, typically is not enough to help this condition completely resolve.
Steroid injections done by a trained physician is also a common treatment options that has good results. This local injection at the site of pain and inflammation helps to reduce symptoms and allows for healing through rehabilitation.
Formal rehabilitative therapy, under the direction of an athletic trainer or physical therapist, can be very effective in improving symptoms and restoring function. These professionals in conjunction with the coach can evaluate and correct errors in form.
Finally, extracorporeal shock therapy should be mentioned as it is a relatively new modality with claims for treatment of lateral epicondylitis. This treatment uses repetitive blasts of sound waves to theoretically treat deep tissues. Several studies have disputed this claim and currently Shock therapy is not recommended for tennis elbow.