Tennis elbow

Introduction

A pathologic condition of the wrist extensor muscles at their origin on the lateral epicondyle of the humerus, also referred to as lateral epicondylitis, or tennis elbow. In fact, non-tennis players are more probable than tennis players to have the condition. The other term for it is “lateral epicondylitis.” This is also improper, as the condition is typically located just below the lateral epicondyle.

Most pathogenic changes occur in the tendinous origin of the extensor carpi radialis brevis (ECRB). Overuse can lead the tendons that bend the wrist backward away from the palm to swell and generate microscopic tears, or microtears, in the tendon where it attaches to the bone. This can cause pain and make it difficult for the diagnosed muscle to move.

The extensor carpi radialis brevis tendon is most likely the one that is affected. There have also been modifications to the musculotendinous components of the extensor digitorum communis, extensor carpi ulnaris, and extensor radialis longus. The primary cause of tennis elbow is repetitive strain put on by holding something continually and/or extending the wrist.

People who play badminton, squash, tennis, or any other sport that requires repeated wrist extension, radial deviation, and/or forearm supination are more susceptible to it.

Elbow Anatomy

The elbow joint is located between the arm and the forearm in the upper limb; it is a synovial joint. Thera are three bones articulate in the elbow joint: 1. the forearm’s ulna, 2. radius, and 3. humerus.

These joints contain three bones.

• The humerus
• The radius
• The ulna.

The humeroulnar joint: the joint between the trochlea on the medial aspect of the distal end of the humerus and the trochlear notch on the proximal ulna.

The humeroradial joint : attachment of the capitulum, which is situated on the side of the distal end of the humerus, to the head of the radius.

Ligaments of the elbow joint:

The ulnar collateral ligament joins the humerus’s medial epicondyle to the ulna’s coronoid process. It has a triangular form and is separated into three sections: the anterior, posterior, and inferior bands.

The radial collateral Ligament lateral epicondyle of the humerus is where the radial collateral ligament is weakly attached. The distal fibers join together with the supinator and extensor carpi radialis brevis muscles’ fibers, as well as the annular ligament that encloses the radius head.

The annular ligament : by holding the ulna and radius together at their proximal articulation, the annular ligament reinforces the joint.

The quadrate ligament : At this joint, the quadrate ligament is also present and is liable for sustaining continuous tension during the forearm’s pronation and supination movements.

A significant portion of the motions at the elbow joint involve the forearm. At the elbow joint of the arm and the forearm, less angle is formed when the forearm is bent. an extension is the act of stretching the angle formed by the arm and forearm. The anterior compartment and posterior compartment of the arm are the two muscle groups responsible for these movements.

Flexion

Most of the flexion-producing muscles are situated in the arm’s anterior compartment. This compartment includes two muscles that are responsible for elbow flexion.

• Biceps Brachii
• Brachialis

Extension

The action of moving the forearm back to its anatomical position from a flexed position involves increasing the elbow joint’s angle, which is known as extension. The triceps brachii muscle is the only one used for extension. In the arm’s posterior compartment, it is the main muscle.

• Triceps brachii

Etiology

• Tennis elbow can be an overuse injury caused mostly by repetitive strain from holding objects repeatedly or extending the wrist.
• While tennis players have historically experienced it, it can arise from any sport requiring repetitive wrist extension, radial deviation, and/or forearm supination.
• Athletes that participate in badminton, squash, and other sports or activities involving similar movements show it. In the case of sports patients, this illness tends to come on by weak mechanics and technique or insufficient equipment.
• Between the ages of 30 and 55, individuals who have lateral epicondylitis typically have poor-conditioned muscles.
• Ninety-five percent of incidents of tennis elbow occur in non-tennis players.
• Tennis elbow symptoms range in severity and affect 10% to 50% of regular tennis players at some point in their tennis activities.

Pathophysiology

• The primary cause of this condition is a degenerative process put on by overuse of the common extensor tendon and the extensor carpi radialis brevis.
• Repetitive trauma or overuse in that area leads to microtears and fibrosis in the affected tissues. to vascular ingrowth and microtears in the involved tissues, also known as angiofibroblastic hyperplasia.
• Previous histologic investigations describing its microscopic look and characteristics have led to the term being defined as angiofibroblastic dysplasia.
• More suggested that tendinosis, as compared to tendinitis, be the appropriate word for the degenerative process.
• Sometimes, a prolonged history of flexion-extension or pronation-supination activities (such as spinning a screwdriver or carrying heavy bags with the palm down) is identified.

Clinical Features

• The most typical symptom of tennis elbow is recurrent pain on the outside of the upper forearm, directly below the elbow’s bend. In addition, there was pain from the wrist all the way down the arm.
• Forearm twisting may result in tennis elbow pain. This is obvious when you fully extend your forearm or turn a door handle.
• Any move involving repeated wrist extension against resistance is related to extensor tendinopathy. This includes both recreational and professional activities such as carpentry, bricklaying, sewing, and knitting, as well as sports such as badminton, squash, and tennis.
• The most common is a gradual start to the pain that occurs 24–72 hours after performing an unusual task that involves repeatedly extending the wrist. This typically occurs after anyone spends the weekend using a screwdriver or laying bricks.
• It can also be observed after prolonged knitting or stitching.
• sudden onset of lateral elbow pain on a single wrist extension exercise, such as lifting a heavy object or a strong backhand stroke in tennis.

Symptoms

• Elbow pain that starts as mild but gradually increases.
• More pain when grasping an object or shaking hands.
• Weak grip holding.
• Pain when use tools, lifting items, or opening jars.
• Pain during service time in athlete such as tennis,badminton, squash, and other sports or activities involving similar movements pattern.

Causes

• Sports involving hefty objects throwing, such disc or javelin, also have been linked to tennis elbow.
• Occupational workers such as painters, plumbers, bricklayers, carpenters, cooks, and construction workers who use screwdrivers, chainsaws, or twisting hand tools can also experience tennis elbow.
• Improper racquet “dampening,” incorrect grip size or string tension, and underlying weak arm, elbow, and shoulder muscles. Tennis elbow is caused or triggered by too-small tennis grips.
• Tennis elbow is connected to the wrist and finger extension motion. When someone uses this type of movement, they can “snap” or flick their wrist, such as when swinging a racquet.

Diagnosis

There are different methods used to diagnose the tennis elbow. Basically start with player/patient complaining, history, examination, and investigation.

Patient complaining of pain over the lateral side of the elbow during heavy weight lifting, elbow bending, chopping, and typing.

History

• A history of prolonged and repetitive pronation-supination or flexion-extension activities has been identified (e.g., twisting a screwdriver, moving heavy luggage with the palm down). One very common reason is holding a hefty briefcase tightly. Baseball, bowling, gardening, golf, raking leaves, and baseball may result in lateral epicondylitis.
• Patients usually report pain that starts gradually, but when asked further, they usually report a history of overuse rather than a single traumatic event that triggered the pain. Usually, the pain starts one to three days after a different activity that requires repeated wrist extension.
• The history may reveal the use of new equipment or an unusual training circumstance, such as an athlete’s prolonged or hard workout. Acute strains or injuries from activities like lifting a large object or striking a forceful backhand stroke in a game of tennis can also cause this condition.

Physical Examination

Palpation: The localized tenderness present over the distal area is approximately 1 to 2 cm from the lateral epicondyle itself. On palpation, the tendon may have some amount of pain and discomfort, as well as some degree of tightness present in the connecting muscle. A physiotherapist palpates the tendon and recognizes abnormalities. Elbow extension might be slightly restricted.

Mills’ test

Resisted wrist extension, particularly when the wrist is pronated and radially deviated, reproduces the pain.

Maudsley test

When the elbow is fully extended, the patient may feel pain when trying to extend the middle finger at the metacarpophalangeal joint.

Investigation

• Tennis elbow may need, in a serious stage, to be diagnosed by X-rays, magnetic resonance imaging (MRI), and electromyography (EMG) in order to rule out serious causes of pain, like compression of the nerves, rheumatoid arthritis, and neck injuries.
• Because tennis elbow is a self-limiting condition, it normally gets better on its own, but there are several therapies that can help with symptoms and speed recovery.

Ultrasound

In screening patients who have lateral elbow pain, ultrasound testing may prove to be a helpful diagnostic technique. Both the degree of tendon damage and the presence of a bursa can be seen using an ultrasound.

MRI & X-ray

Because an MRI covers the soft tissues, muscles, and tendons inside the arm, it provides a more detailed image than an X-ray. After a year, if the pain in the outside of the elbow does not improve with conservative measures, this may be required.

Electromyography (EMG)

If the nerves are compressed, electromyography (EMG) may be used to identify it.

Differantial Diagnosis

Lateral epicondylitis

• Localize tenderness over the lateral epicondlye.
• Pain aggravated during activity.
• Provocating factors: Resisted wrist extension & forearm pronation
• Neurological finding not present

Radial tunnel syndrome

• Type of pain : diffuse forearm pain
• site of pain: pain is present at rest & is more distal than in lateral epicondylitis.
• Provocating factors : refused to extend or retract the middle finger
• Neurological Finding : present

Cervical radiculopathy

• Type of pain: common lateral arm pain, stiffness, and/or neck pain.
• site of pain: neck range of motion limited, triggering test positive.
• Neurological Finding : present, abnormal findings from a reflex, sensory, or motor assessment; abnormal EMGINCS

Intra-articular pathology :

• Type of pain: generalized elbow pain.
• Provocating Factors: axial compression test.
• Neurological findings : not present.

Precaution

Before starting an exercise regimen, always get doctor advice. To rule out a significant injury, such as a tear of a muscle or tendon, it’s important to have a complete evaluation.

Don’t start any activity until the inflammation has decreased because they may aggravate the problem.

To make sure you are performing the exercises correctly, see a physical or occupational therapist if the pain continues after engaging in physical activity. Rest and apply ice to your elbow and forearm.

Do not start any weightlifting activity.

Treatment

Planning a patient’s course of treatment depends on the nature and severity of their existing issue. The tennis elbow condition is most probably recovered by physiotherapy treatment such as modalities for pain relief, isometric exercise, and strength & conditioning. 80 to 95% of patients heal without surgery. Only when physical therapy treatment fails and then needs of alternative therapies, like medication or lifestyle modifications and surgery.

Medical treatment

When it is not contraindicated, we use over-the-counter medications like ibuprofen or cyclooxygenase-2 (COX-2) inhibitors like celecoxib (Celebrex).

Injecting the patient with platelet-rich plasma (PRP), which is made from their blood, is one recently developed treatment. PRP contains proteins that contribute to the process of healing. While still at the investigation stage, the American Academy of Orthopaedic Surgeons (AAOS) describes this treatment as promising.

In addition, using analgesics like paracetamol may help in the reduction of minor pain.

Surgical Treatment

Tennis elbow surgery should not be considered until the patient’s symptoms have not improved after more than a year of nonoperative treatment. Tennis elbow pain has been treated using a variety of surgeries.

Excision of tom, scarred ECRB origin, granulation tissue removal, and cortical drilling (down to subchondral bone) have all been suggested by numerous writers as ways of promoting neovascularization.

In comparison to open treatments, arthroscopic treatment of lateral epicondylitis has a similar success rate and presents a number of possible advantages. When the lesion is treated directly, its typical extensor origin is still present. Intra-articular testing for additional conditions is also possible with arthroscopy. It also makes it possible to return to work or sports early and to recover from surgery more quickly.

Physiotherapy Treatment

The basic principles of treating soft tissue injuries are applicable. Pain management, promoting the healing process, restoring flexibility and strength, treating related issues (such as high neural stress, referred pain), a gradual return to activities with additional support, and addressing the risk factors are all required.

We can reduce pain and promote muscle healing by using therapeutic ultrasound, applying a towel-wrapped cold compress, or performing muscle-stirring exercises several times a day for a short period of time.

Additionally, it has been shown that occupational or physiotherapy that starts with stretching and forearm strengthening and progresses to eccentric muscle strengthening of the common extensor tendon is beneficial.

Activity Limitation

• The key to progress for non-athletes is to stop doing awkward tasks (like repeatedly opening the valve, typing, or chopping, etc.)
• Modifying one’s activities to prevent grasping when in a pronated position and instead raise with both arms in a controlled supination could help the problem.
• When possible, lift with the palms up, or supination, and use both upper extremities in a way that minimizes forced elbow extension, wrist extension, and supination.
• For the player, it is important to avoid ball impacts if there is no forward body weight transference.
• It’s necessary to adjust the stroke mechanics if a poor or late backhand hurts.
• Supporting the elbows with layered towels can assist if typing with unsupported arms makes the pain worse.

Connterforce Bracing (Tennis Elbow Bracing)

Bracing is only used during vigorous playing or other aggravating activities.

The band’s tension is adjusted to a comfortable level while the muscles are relaxed, preventing the finger and wrist extensors from contracting to their maximum capacity.

The band is placed two fingerbreadths away from the lateral epicondyle’s painful region.

Pain reduction

R: In the initial stage, rest is necessary for tennis elbow.

I: Ice packs (15 minutes) or ice massages (5 minutes) as part of cryotherapy. As needed to control inflammation and pain. Ice packs (15 minutes) or ice massages (5 minutes) as part of cryotherapy.

Ultrasound : For pain & tenderness reduction, it promotes the healing process. Frequency : 1.5 w/cm2, Mode : continuous mode, Duration: 5 min, 5 days/week.

Laser Therapy

Low-intensity lasers or light-emitting diodes are used in laser therapy, also known as Low-Level Laser Therapy (LLLT), to enhance cellular activity and help in tissue healing. It is commonly used to improve blood flow, reduce inflammation, and promote the healing of injured tissues during conditions such tennis elbow. It is commonly recognized that this non-invasive therapy can lessen pain while enhancing the body’s natural healing processes.

Taping: The diamond taping method is useful for pain reduction, and improving grip strength and functional performance.

Dry needling: Encourage the release of pain and lessen trigger points.

Deep friction massage: advantageous for promoting healing and relieving soreness. It is administered transversely to the affected tissue for ten minutes, or until the patient or player feels numbed. Duration: 28 hours.

Range of motion & Flexibility exercise

End-range and passive stretching—with the elbow fully extended and the wrist slightly bent—are the primary objectives of range-of-motion exercises.Wi

Wrist Extensor Stretching & ROM: This technique is useful for improving ROM and muscle flexibility. Extensor wrist stretches for lateral epicondylitis treatments. The patient stretches five or six times, holding each stretch for 30 seconds with the elbow extended, wrist flexion, and minor ulnar deviation. Perform this twice or three times daily.

Wrist Flexor Stretching & ROM: This technique is useful for improving ROM and muscle flexibility. Stretching the wrist flexor wad in cases of medial epicondylitis. The patient repeats five or six stretches, holding each one for 30 seconds, with the elbow, wrist, and mild radial deviation extended. Perform this twice or three times daily.

Strengthening exercise

For grip strength as well as wrist extensor, wrist flexor, biceps, triceps, and rotator cuff strength, a mild strengthening program should be used.Before beginning gradual strengthening exercises, the initial inflammatory phase must have ended, and there must have been two weeks of pain-free daily activities.

Wrist curls exercise : With a hand over your knee, sit. Bend the wrist ten times while holding a one- to two-pound weight with the palm up (supination). Raise the weight to two sets of ten each day, and then raise it by one pound to five or six pounds. Continue pronating (palm down), but only with 1 kg.

Forearm strengthening exercise: Keeping the palm down, extend the arm in front of the body. After squeezing their wrist into a closed fist, the patient keeps it there for ten seconds. Afterwards, the patient desires to apply pressure with the opposite hand. Gradually progress to twenty repetitions, two or three times a day, after holding for five repeats for ten seconds.

Elbow flexion and extension exercises: Below situated picture shows stregthening exercise of elbow flexion and extension with theraband.

Patient position: sitting at the edge of plinth.

Procedure: Front and center in front of the patient or player is where the theraband wraps. Over the plinth, elbow is positioned. 10 times around.

Patient position : sitting, theraband wrapped below the foot, elbow placed over the thigh.

Ball squeeze exercise

Patient position : stading/sitting

Procedure : grasping a stress ball or tennis ball in one hand.

Elbow curls for strengthening

Patient position : standing or sitting with light weight dumbbell, water bottle, or weightcuff

Procedure : Perform prescribed curls, bending your elbow towards your arm with wrist in neutral position.

Repetition : In starting phase, start with minimal weight Tennis elbow recovery is made easier with this exercise, that strengthens the forearm muscles.

How to prevent tennis elbow

• Performing forearm exercises that maintain their strength and flexibility.
• Assuring that you are performing each activity or sport with the proper equipment and technique.
• If bending or straightening is painful, then take your elbow in the resting position.
• Icing your elbow following vigorous physical activity.
• In athletes while playing proper gripping, strengthening, and playing, necessary.
• Proper plyometric for the athlete.
• Proper warm and cool sown for the athlete.

Home advice

• Rest: Avoid free activities that aggravate your elbow pain.
• Painkillers: Use pain medicines if it is necessary, such as naproxen sodium (Aleve) or ibuprofen (Advil, Motrin IB, etc.).
• Ice: Use an ice pack or cold compress for fifteen minutes, at least three or four times a day.

Summary

Tennis elbow is a pathological condition of the wrist extensor muscles at their origin on the lateral epicondyle of the humerus, also referred to as lateral epicondylitis or tennis elbow. In fact, non-tennis players are more likely than tennis players to have the condition. The other term for it is “lateral epicondylitis.” This is also incorrect, as the condition is typically located just below the lateral epicondyle. Tennis elbow can be present in both population athletes and non-athletes. The three bones that make up an elbow are: humerus, ulna, and radius, and it has four ligaments – 1. radial collateral ligament, 2. ulnar collateral ligament, 3.quadrate ligament, and 4. the annular ligament.

Tennis elbow can be an overuse injury caused mostly by repetitive strain from holding objects repeatedly or extending the wrist, most commonly affecting individuals aged between 30 and 35 years old. The pathophysiology of tennis elbow involves repetitive trauma or overuse in that area, leading to microtears and fibrosis in the affected tissues.

Clinical features of tennis elbow include a gradual onset of pain that occurs 24–72 hours after performing an unusual task involving repeatedly extending the wrist; this typically happens after someone spends a weekend using a screwdriver or laying bricks. Causes include improper gripping methods in athletes, improper heavy weightlifting techniques, and inappropriate computer typing habits.

Diagnosis done through certain data such as patient/player history, physical examination, investigation, and differential diagnosis.

FAQ

Referance

• Image 1: Medical News. September 7, 2022. Why Does Tennis Elbow Occur? What Causes Tennis Elbow? https://www.news-medical.net/health/.
• Varacallo, M., and B. K. Buchanan (2023, August 4). Tennis elbow is known as lateral epicondylitis. NCBI Bookshelf: StatPearls. Books/NBK431092/https://www.ncbi.nlm.nih.gov.
• Image 2, elbow joints: Kenhub. https://www.kenhub.com/en/library/anatomy.
• Kraft, S. (November 27, 2023). Everything you should know about elbow tennis.https://www.medicalnewstoday.com/articles/175848.
• Image 5, AmitPrashar. February 11, 2024. [Slide show] TENNIS ELBOW (Lateral Epicondylitis).pptx. Tennis elbow lateral epicondylitis pptx. SlideShare. https://www.slideshare.net/slideshow
• Scaccia, A. Sept. 18, 2018. How to Recognize and Handle an Overextended Elbow. The website Healthline provides information on hyperextended elbows and their prospects.
• Brahmbhatt, A. (2023, March 8). The Ultimate Guide to Managing and Treating Tennis Elbow: Expert Tips and Exercises. Tatva. https://www.physiotattva.com/blog/