“Tennis Elbow”, or the more correct medical term, lateral epicondylitis, was first described in 1882 in a British medical journal and termed “lawn tennis arm”. Specifically, the term refers to inflammation of the tendon insertions on the “outer” or lateral side of the elbow. The common extensor origin includes the extensor carpi radialis longus (ECRL), extensor carpi radialis brevis (ECRB), the extensor digitorum communis (EDC), and the extensor carpi ulnaris tendons (ECU).

A wide spectrum of theories on the pathophysiology of tennis elbow has been proposed. The current agreed upon consensus based upon both clinical and surgical evidence suggests that that inflammation is initiated as a microtear within the origin of the ECRB tendon. With continued stresses and loads across the outer elbow the tear progresses becomes more inflammatory and symptomatic in nature.

Etiology

Symptoms most commonly occur in the fourth and fifth decades. The occurrence in males and females is relatively equal. It’s estimated that 10 – 50% of persons who play tennis regularly will experience symptoms of tennis elbow at some point during their careers. The risk of developing tennis elbow can be 2 – 3.5 times greater in players with over 2 hours of racket time per week. Players over the age of 40 have a 2 – 4 fold increase in risk of developing tennis elbow.

Biomechanics

The greatest muscle activity during the ground strokes has been noted to be in those muscles stabilizing the wrist, specifically, the ECRB, ECRL, and EDC. Of the three the ECRB has been noted to have the greatest activity during the acceleration and follow through phases of the ground stroke. Optimal stability for these phases of the groundstroke is maintained by the position of the wrist in extension and radial deviation.

Risk Factors

Several specific technique, equipment, and playing surface factors have been implicated in the development of lateral epicondylitis. A higher incidence of poor stroke mechanics, such leading with the flexed elbow and striking the ball off center on the racket, has been identified. Improper grip size, racket weight, and racket stringing generate higher loads in the muscles affected. Harder court surfaces impart greater momentum to the ball and subsequently increase the force transmitted through the racket to the extensor muscles.

Diagnosis

Tennis elbow is characterized by pain on the lateral side of the elbow. Sometimes pain will extend into the forearm. Typically pain is insidious in onset. On examination tenderness is present on the lateral side of the elbow over the lateral epicondyle common tendon. Resisted wrist and finger extension with the elbow in extension increases pain. Range of motion of the elbow and wrist is usually unaffected. Weakness that occurs is usually secondary to pain. X-rays are usually normal. MRI scans usually show inflammation and tearing of the ECRB tendon and surrounding tissues. Other potential diagnoses include compression of the radial or posterior interosseous nerves at the elbow, degenerative arthritis in the neck resulting in nerve compression with pain at the elbow, and arthritic conditions of the elbow.

Treatment

Nonoperative

Greater than ninety percent of all episodes can usually be taken care of with nonoperative management. The objectives of treatment are to reduce pain and inflammation with guided return to activity.

Phase one should include cessation of the offending activity, nonsteroidal anti-inflammatory medication for a 2 week period, physical therapy, and evaluation of playing habits, equipment and playing surfaces. Typically a tennis elbow strap is provided as well as a stabilizing splint to the wrist to be used in the acute phases. The strap, or “counterforce brace”, use can be continued even after return to the sport. The brace first used in 1965, has been shown to significantly reduce muscle activity in the lateral forearm muscles in healthy individuals.

Physical therapy should involve not only techniques to reduce discomfort, but proper stretching and strengthening exercises for the entire upper extremity to in order to enable long term prevention.

Injection with corticosteroid can be a very effective method of alleviating discomfort if the initial measures are not effective in the first 2 – 4 wks. Side effects can include atrophy of the fat in the underlying skin and discoloration of the skin in darker skinned individuals.

Phase two should result in a gradual return to activity with avoidance of the known abusive maneuvers. Stroke mechanics should be reassessed, slower court surfaces can be initially used (i.e. clay), rackets can be lightened, racket of low vibration materials can be used, grip should be properly sized and string tension can be reduced. A two-handed backhand can also significantly reduce isolated loads to the outer elbow in the dominant arm.

Alternative methods of treatment that have been used more recently in refractory cases include shockwave therapy, injection of buffered platelet rich plasma, and even acupuncture. Results of such methods have all shown some promise but not yet widespread acceptance.

Operative

Five to fifteen percent of individuals will have reoccurrence of their symptoms. Failure of response to nonoperative treatment for a 6 – 12 month period may potentially be an indication for surgical management.

Open surgical treatment generally involves a relatively short procedure requiring either regional block or general anesthesia as an outpatient. An incision is typically made on the lateral side of the elbow 4 – 5 cm in length. The goal of treatment is surgical debridement of the diseased tendon by a cutting out of the degenerative tissue and stimulation of healing by drilling of the underlying bone. Postoperatively a splint is generally worn for the first week and immediate physical therapy is initiated with range of motion exercises. Strengthening is begun when tolerated. Return to full normal unrestricted activities generally occurs between 8 and 12 weeks.

Arthroscopic management has been more recently introduced as a method of treatment. The advantage becomes the ability to address the pathology with a more limited surgical approach from inside the joint. Recovery generally follows the same course with potentially slightly shorter times to return to full activity. The primary disadvantage may be the inability to potentially address other concomitant lesions causing pain with particular reference to entrapment of the posterior interosseous nerve.

Keith Meister, MD
Head Team Physician Texas Rangers Baseball / Dallas Stars Hockey
Director TMI Sports Medicine / TMI Sports Performance

Office – 817-419-0303 / 972-623-2629
Email – keithmeister@tmisportsmed.com