Introduction

"Tennis Elbow" is a common complaint among sports people and manual workers, often experienced by, but not exclusive to, tennis players. It can be a painful and sometimes debilitating condition, requiring a committed approach to treatment if optimal recovery is to be made.

Definition

Tennis elbow is a blanket term used to describe lateral epicondylitis, extensor tendinosus, or extensor tendonitis, all of which cause pain around the lateral elbow region. While each of these three conditions differ in their specific pathologies, the most common description of the primary pathological process refers to a degeneration (tendinosis) of the extensor carpi radialis brevis tendon (ECRB), usually within 1-2 cm of its attachment to the lateral epicondyle of the humerus. This results in tennis elbow being primarily a mechanical type of overuse injury, featuring pain associated with and aggravated by movement, particularly of the wrist.

Aetiology

Tears to the tendon of the ECRB muscle and/or inflammatory changes as a result aging, repeated overuse, or trauma, contribute to degeneration of the tendon. Poor blood supply to the area (which is a normal anatomical feature) prolongs healing, as does repeated use and failure to rest.

Inflammatory signs such as pain and stiffness following rest, relief with mild activity (a "warming up effect") may indicate more of a tendinitis (inflammation of the tendon) rather than a degenerative process.

The Causes of Tennis Elbow

Causes and contributing factors are varied, but in general they are related to repetitive injury as a result of one or more of the following:

• poor sports technique (such as a tennis backhand stroke)
• occupational tasks involving repetitve movements of the wrist and hands.
• degeneration either as a primary cause, or secondary to injury
• injury either as a primary cause, or secondary to degeneration

Signs & Symptoms

Some of the signs and symptoms which may be related to tennis elbow include:

• tenderness over the lateral aspect of the forearm – lateral epicondyle, extensor tendons, muscle belly, which may radiate into the forearm
• decreased grip strength and pain on gripping
• decreased strength and pain on active wrist extension
• pain on stretch of ECRB
• pain on resisted radial deviation and extension of the middle finger
• may disturb sleep when severe
• chronic states – usually a loss of end range elbow extension and/or adduction with extension (due to intimate relationship between ECRB and capsule/ligaments of the elbow complex
• the condition may be irritable (can be "stirred up" easily)
  onset may be gradual or related to a specific incident (insidious or traumatic)

Treatment Options

Treatment of tennis elbow aims at reducing pain and inflammation, promoting the healing process, and regaining normal strength and flexibility. No single treatment technique has been proven totally effective in all cases. Therefore, tennis elbow often requires a combination of treatment techniques.

Some of the methods in use to treat the condition include:

• rest from aggravating activity
• ice, ice massage
• medications – anti-inflammatory
• injections – corticosteroids
• ultrasound
• friction massage
• myofascial release
• mobilisation
• strapping (bracing)
• correct predisposing factors
• acupuncture
• iontophoresis
• phonophoresis
• strengthening exercises
• stretching exercises

It is also important to identify the causative factors and address these, not just the symptoms. Your physiotherapist will help identify the predisposing factors and implement a program most appropriate for your condition.

Cases in which conservative methods of treatment such as those above fail to resolve the problem may indicate the need for surgical intervention. The outcome following surgery is quite good, however is usually only considered following a long unsuccessful program of conservative treatment.

Other Causes of Pain in the elbow

Tennis elbow needs to be differentiated from a variety of other conditions that can cause pain around the elbow:

• referred pain from cervical spine (especially C5-C6)
• referred pain from upper thoracic spine
• increased neural tension
• synovitis of the radiohumeral joint
• radiohumeral bursitis
• posterior interosseus nerve entrapment
• osteochondritis dissecans of the capitellum/radius
• osteoarthritis of the elbow
• lateral epicondyle epiphysis injuries
• lateral epicondyle avulsion fractures
• lateral ligament sprain
• radial nerve entrapment

References

Brukner P, Khan K (1993) Clinical Sports Medicine. McGraw-Hill, Sydney (pp 220-228)

Zuluaga et al (1995) Sports Physiotherapy: Applied Science and Practice. Churchill Livingstone, Melbourne (pp 416-426)

Ollivierre C, Nirschl R (1996) Tennis Elbow: Current Concepts of Treatment and Rehabilitation. Sports Medicine. 22(2): 133-139.

Thurston A (1998) Conservative and Surgical Treatment of Tennis Elbow: A Study of Outcome. Australian and New Zealand Journal of Surgery. 68:568-572.

Other Journal References Related to Tennis Elbow