Anatomy

The elbow joint is made up of three bones. These include the humerus of the upper arm and the radius and ulna of the forearm. Tennis elbow or lateral epicondyl-algia/itis is a condition affecting the outer part of the elbow resulting in pain and tenderness at a point called the lateral epicondyle.

More specifically, tenderness is focussed to a line about 1-2 cm above the lateral epicondyle which is the common insertion point for the muscle bulk of the wrist extensor muscles that cross the outer aspect of the elbow joint – known as the common extensor origin (CEO).

These muscles include:

• Extensor carpi radialis brevis, most commonly (ECRB);
• Extensor digitorum (ED);
• Extensor indicis (EI);
• Extensor digiti minimi (EDM).

Irritation at this point in the elbow may affect the radial nerve of the upper limb as it passes just in front of the CEO and is commonly linked with cervical (neck) and upper thoracic (middle back) abnormalities, particularly of the C5-6 (mid-neck) region.

Cause

Tennis elbow is most commonly associated with activities involving repetitive extension or bending back of the wrist. The extensor muscles become overworked, which overloads the tendon where it attaches to the elbow. Racquet sports like tennis, squash and badminton as well as leisurely and occupational activities such as plumbing, bricklaying, painting, knitting and computer use can lead to this irritation. It usually affects people between the ages of 40 and 50, but may affect anyone if they have the risk factors.

Tennis specific risk factors that can lead to the development of tennis elbow include:

• playing with a new racquet;
• gripping the racquet too tightly if the handle is too small;
• playing with wet, heavy balls;
• hitting against resistance e.g. into wind;
• excessive bending at the wrist with a backhand stroke;
• incorrect positioning to transfer the body weight through the hit and instead relying exclusively on the forearm muscles for power;
• strings of the racquet too tight.

Professional tennis players don’t get tennis elbow as their bodies are conditioned to meet the demands and their technique incorporates leg and trunk movements to decrease the reliance on the forearm muscles.

Symptoms

The maximal area of pain or tenderness is usually felt at the CEO as mentioned above. Pain in this area can typically be reproduced with resisted wrist extension – particularly with the wrist pronated (turned palm-side down) and radially deviated (towards the thumb), and with resisted extension of the middle finger. There may also be excessive tightness and hypersensitivity felt throughout the muscle belly of the ECRB. Associated weakness of the forearm muscles will make activities such as gripping a racquet, turning a door handle or shaking hands more difficult.

The onset of symptoms are most commonly insidious, occurring 24-72 hours following a bout of activity involving repetitive wrist extension that the person may not have been accustomed to. The symptoms will often develop gradually, initially only mild, but slowly worsening over a period of weeks or months.

There can also be an acute or sudden onset of lateral elbow pain following a single instance of activity overexerting the wrist extensors e.g. attempting a backhand shot with poor technique.

It has been suggested that the insidious onset of symptoms correlates to microscopic tears to the tendon while acute onset involves macroscopic tearing.

Treatment

The vast majority of patients (up to 90%) have success with non-surgical management. Rest is an important aspect of treatment to reduce the cycle of aggravation and give the soft tissue irritation a chance to settle. This is usually combined with non-steroirdal anti-inflammatories (e.g. voltaren, ibuprofen) which help to ease pain and decrease swelling.

Physiotherapy is an essential part of recovery and may include:

• Soft tissue release to reduce tension at the CEO;
• Ultrasound for traumatic CEO strains in the early phase of healing;
• Elbow joint mobilisation or joint glides to reduce elbow stiffness and improve painfree range at the elbow;
• Progressive eccentric strengthening or isometric loading for the extensors of the wrist;
• Upper limb nerve stretches to reduce neural irritation;
• Cervical (neck) mobilisations to reduce stiffness and restore full range of motion of the neck;
• Taping or brace support to offload the forearm extensors;
• Strengthening of the rotator cuff of the shoulder +/- the posterior deltoid;
• Ergonomic advice and to improve workstation postures and decrease stress on the structures involved;
• Modifications to equipment (e.g. thickening the grip on a tennis racquet or wrist keyboard wrist support) to reduce effort.

If conservative management fails to reduce symptoms completely within 3-6 months then steroid injections or autologous blood injections can be tried. If symptoms persist longer than 6-12 months then surgical management may be required.