Dr. Kevin Yip

Dr Kevin Yip
Orthopaedic Surgeon
MBBS(UK), FRCS(EDIN), FAM(SING), FHKCOS(ORTHO)

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Tennis Elbow (Lateral Epicondylitis, Lateral Elbow Tendinosis)

Tennis is played by people of all ages, as it is a sport which in general does not produce severe medical problems. Problems do occur, however, in the elbow region. It should be remembered that only 5% of
people suffering from tennis elbow relate the injury to tennis. This injury occurs in other racket sports such as squash, badminton, and table tennis. Golfers and others can also be affected, as well as those who carry out repetitive, one-sided movements in their jobs (e.g. electricians, carpenters) or leisure activities (e.g. needlework, knitting, gardening).

Etiology

Lateral elbow tendinosis is most common in tennis players 35–50 years of age. This group is characterized by a high activity level and they often play tennis three times a week or more, for at least 30 minutes per session. It has been shown that 45% of the athletes who play tennis daily, or 20% of those who play twice a week, may at certain stages suffer from lateral elbow tendinosis. Frequency of play has a direct relationship with pain. The more frequently a person plays, the greater is the incidence of pain. Players of higher ability, who play longer and practice more, more commonly have a history of elbow pain.

Tennis players most likely to sustain lateral elbow tendinosis are those who have demanding techniques and inadequate fitness levels. Faulty technique is one of the most common causes for lateral elbow
tendinosis, especially a faulty backhand. The serve may also be associated with elbow pain.

Pathology

The pathoanatomy of lateral elbow tendinosis related to tennis involves primarily the extensor carpi radialis brevis and secondarily the extensor digitorum communis muscle tendons. The bellies of the relevant
muscles are all located in the forearm, while the long tendons bridge the elbow and wrist joints, and insert on the metacarpals or phalanges (fingerbones). The lateral epicondyle of the humerus forms a common
origin for at least parts of all the extensors of the wrist and fingers.

The disorder represents a degenerative process that is secondary to tensile overuse fatigue, weakness, and possibly avascular changes (poor circulation). There are usually no inflammatory cells present. The term ‘tendinosis’ is therefore replacing the term ‘tendinitis’.

Symptoms and diagnosis

– There is a history of repetitive activity or overuse, such as playing tennis intensively at a training camp, or resuming playing after a period of little activity.
– Pain mainly affects the lateral aspect of the elbow, but can also radiate upwards along the upper arm and downwards along the outside of the forearm.
– Weakness in the wrist can cause difficulty in carrying out such simple movements as lifting a plate or a coffee cup, opening a car door, wringing out a wet dishcloth, and shaking hands.
– A distinct tender point is elicited by pressure or percussion over the lateral epicondyle.
– Pain occurs over the lateral epicondyle when the hand is dorsiflexed at the wrist against resistance. This sign alone is sufficient to justify a diagnosis of ‘tennis elbow’.
– A positive middle finger test: there is pain over the lateral elbow when the middle finger is extended against resistance.

Involvement of the extensor carpi radialis brevis is typical in tennis players. In lateral elbow tendinosis due to other causes, e.g. industrial work, it seems that the extensor digitorum communis is typically involved. This also leads to a positive middle finger test. In other words, there may be two different etiologies of lateral elbow tendinosis with different locations of the problem. An accurate diagnosis of tendinosis includes an evaluation of the magnitude of pathological change, which is helpful as a prognostic predictor, as well as formulating the treatment protocol. The patient’s description
of time and intensity of pain is the best guide to evaluation.

The elbow can be X-rayed to exclude a loose body in the joint or a fracture. Other possible diagnoses are rheumatic disorders, trapping of a nerve (the deep branch of the radial nerve or the ulnar nerve), and
radiating pain caused by degenerative changes in the spine in the region of the fifth and sixth cervical vertebrae.

Preventive measures

– Correct playing and working techniques are the most important preventive measures.
– Sometimes a forearm brace or a heat retainer can be used as a means of dissipating the forces outwards before they reach the epicondyle.
– Asymmetrical training techniques should be avoided.

In tennis, the following points should be emphasized:

1. Good footwork so that the player approaches the ball correctly.

2. The ball should be hit correctly with the racket and at the right moment.

3. The shoulder and the whole of the body should take part in every stroke so that ‘braking’ does not occur when the ball is hit. The stroke should be followed through and the wrist should be firm.

4. The court surface should be slow in order to decrease the velocity of the ball. Fast surfaces such as grass or concrete cause the ball to hit the racket with increased force, resulting in increased load on the
player’s arm.

5. The balls should be light. Wet or dead balls become heavy.

6. The correct equipment should be used. The racket should be individually selected with regard to playing technique. A casual player should use a light racket, as a heavy racket causes greater load. The
racket should be well-balanced and easy to handle, e.g. when making angled dropshots.

7. A tightly strung racket increases the impact and tension forces. The stringing of the racket should be individually adjusted and should not be too taut. Anyone troubled by tennis elbow should have the
racket strung more loosely. Gut strings give more resilience and less vibration than nylon ones.

8. The size of the racket grip should be carefully chosen in order to fit the hand comfortably. A simple method of determining the appropriate size of grip is to measure the distance between the midline of
the palm of hand and the tip of the middle finger; this distance should equal the grip’s circumference.

9. A large ‘sweet spot’ (center of percussion, the area of the racket face where minimal torsion occurs on impact) is probably an advantage. Hits outside this spot will increase torsion and unwanted forces and vibrations.

Treatment

The treatment should follow the healing response; this includes three phases: (1) an acute inflammatory
phase; (2) a collagen and ground substance production phase; and (3) a maturation and remodeling phase.

The athlete should:
– reduce pain and inflammation when the injury is in its acute stage by the use of cooling for about 2 days (elevation and compression are not needed, as swelling is not a problem);
– rest actively—that is, rest the injured area and avoid movements that trigger pain, but continue with conditioning activity such as running or cycling;
– continue with tennis but avoid the strokes that cause pain;
– apply local heat and use a heat retainer when the injury is no longer in its acute stage;
– treat with ice massage, perhaps alternating with heat treatment;
– try taping the wrist to support the elbow joint under load;
– reduce the load on the extensors with the help of a brace, which should be applied when the arm is relaxed and kept in position until the rehabilitation period is over.

Counter force bracing constrains key muscles groups. An air-filled bladder has been developed as a counterpressure element. This constrictive band caused a significant reduction in integrated
EMG of the extensor carpi radialis brevis and the extensor digitorum communis when compared with controlled values and a standard band. More research is needed to confirm the effect of braces for the treatment of tennis elbow. Clinical experience indicates, however, that the use of such braces is a valuable complementary tool in the treatment of tennis elbow. The elbow bands can be combined with heat-retaining Neoprene sleeves to add the positive effects of heat in stimulating healing.

Strength, stamina, and mobility should be improved by exercises once the pain and inflammation are under control, i.e. the athlete can tolerate the pain of a handshake. The training program should follow the
guidelines set out below.

1. Isometric training of the wrist extensors. The training is carried out with the wrist in three positions: first fully flexed downwards, then in a neutral position, and finally flexed upwards. The joint should not be under load and the exercise should be carried out 30 times a day. The wrist is flexed for 10 seconds at a time. When these exercises can be carried out without any pain, a load of 0.5 kg (1 lb) can be introduced.

2. Dynamic training. An elastic band is slipped over the ends of the fingers, and then an attempt is made to spread the fingers against its resistance. Another method is to extend (concentric) and flex
(eccentric) the wrist with a load of 1–2 kg (2–4 lb) 20 times a day.

3. Flexibility training (static stretching) of the wrist. The joint is bent at an angle of 90° and the opposite hand is used to provide counterpressure. The elbow of the injured arm should be held completely extended and the forearm should be rotated inwards (pronated). The bent wrist is stretched to its outer range and is held there for 4–6 seconds. After 2 seconds rest it is subjected to stretching for another 6–8 seconds. The exercise is repeated 15 times a day.

4. Training of strength and mobility in shoulder and arm.

The doctor may:
– prescribe anti-inflammatory medication;
– prescribe ultrasound treatment, high-voltage galvanic stimulation, or/and transcutaneous nerve stimulation. There is no agreement on which treatment is most appropriate for this common condition;
– prescribe acupuncture;
– administer local steroid injections in persistent cases and if pain interferes with the exercise program.

Injections should be given subperiosteally to the extensor brevis origin. These injections have an early and beneficial effect. During the initial 24–28 hours, increased pain may be experienced. A steroid injection
should be followed by 1–2 weeks’ rest and should not be repeated more than 2 times. Steroid injection seems to be effective for about 3 months, indicating that the patient must continue with the exercise program.
Failed healing is considered to have occurred if there are chronic symptoms of tendinosis pain for more than 6–12 months. If there is poor response to a rehabilitation program, if there is a history of persistent pain, or if the patient has not been able to return to an acceptable quality of life, surgery may be indicated. In patients undergoing surgery it has been found that in 100% the tissue involved was extensor carpi radialis brevis; extensor digitorum communis, especially the anterior edge, was involved in 35%, and there was
osteophyte formation of the lateral epicondyle in 20%. Surgery consists of resection of damaged tissue. The attachment of normal tissues should be maintained and the healthy tissues protected. There should then be quality postoperative rehabilitation. The elbow is protected at 90° for 1 week in a counterforce elbow immobilizer. Strength and endurance resistance exercises usually start 3 weeks after surgery. Postoperatively, 85% experience complete pain relief and full return of strength.

A recurrence rate of 18–66% is reported. The degree of pain prior to treatment is the most important predictor of complete recovery: the greater the pain, the more likely is the treatment to be completely
successful. Arthroscopic treatment of this condition is now being developed.

Healing

A genuine tennis elbow often heals spontaneously and the prognosis is generally good. The symptoms can, however, persist for anything from 2 weeks to 2 years, especially if the athlete continues to load the arm.
Strenuous activity can be resumed when the arm is fully mobile, has regained normal strength, and is painfree. After surgery, 8–10 weeks should elapse before tennis is resumed.

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