Tennis elbow
Encyclopedia
Lateral epicondylitis or lateral epicondylalgia, also known as tennis elbow, shooter's elbow and archer's elbow, is a condition where the outer part of the elbow becomes sore and tender. It is commonly associated with playing tennis
and other racquet sports, though the injury
can happen to almost anyone.
Tennis elbow is an overuse injury occurring in the lateral side of the elbow region, but more specifically, occurs at common extensor tendon
that originates from the lateral epicondyle
. While the common name tennis elbow suggests that people who play tennis may develop this condition, other activities of daily living
may also cause it.
Data
was collected from 113 patients who had tennis elbow and the main factor between them all was overexertion. Sportspersons as well as those who used the same repetitive motion for many years, especially in their profession, suffered from tennis elbow. It was also common in individuals who performed motions they were unaccustomed to. The data also mentioned that the majority of patients suffered tennis elbow in their right arms.
Other descriptions for tennis elbow are lateral epicondylosis, lateral epicondylalgia, or simply lateral elbow pain
.
Lateral epicondylitis is a painful condition at the lateral epicondyle of the humerus. The acute pain that a person might feel occurs as one fully extends the arm. Since the pathogenesis
of this condition is still unknown, an appropriate name is still in the works. Despite the term being tennis elbow, tennis players make up a small number of individuals who suffer from this ailment, often found in manual workers, such as builders and waiters. Bowden states that it should be called lateral elbow syndrome
.
Runge is usually credited for the first description in 1873 of the condition. The term tennis elbow was first used in 1883 by Major in his paper "Lawn-tennis elbow".
The symptoms associated with tennis elbow are, but are not limited to: radiating pain from the outside of your elbow to your forearm
and wrist, pain during extension of wrist, weakness of the forearm, a painful grip while shaking hands or torquing a doorknob, and not being able to hold relatively heavy items in the hand. The pain is similar to the pain of the condition known as Golfer's elbow
but the latter occurs at the medial side of the elbow.
One explanation of how tennis elbow may come about is proposed by Cyriax. The theory states that there are microscopic and macroscopic tears between the common extensor tendon and the periosteum
of the lateral humeral epicondyle. An operation conducted in this study showed that 28 out of 39 patients showed tearing at the tendon cuff. Kaplan stated that the radial nerve
was significantly involved in tennis elbow. He noted the constriction
of the radial nerve by adhesions to the capsule of the radiohumeral joint and the short extensor muscle of the wrist. Evidence found that many differed in how they contracted tennis elbow. Disorders such as calcification of the rotator cuff, bicipital tendinitis, or carpal tunnel syndrome
may increase chances of tennis elbow.
of lateral epicondylitis is degenerative. Non-inflammatory, chronic degenerative changes of the origin of the extensor carpi radialis brevis (ECRB) muscle
are identified in surgical pathology
specimens. It is unclear if the pathology is affected by prior injection of corticosteroid
.
Among tennis players, tennis elbow is believed to be caused by the repetitive nature of hitting thousands and thousands of tennis balls which lead to tiny tears in the forearm tendon attachment at the elbow.
The extensor digiti minimi also has a small origin site medial to the elbow which can be affected by this condition. The muscle involves the extension of the little finger
and some extension of the wrist allowing for adaption to "snap" or flick the wrist – usually associated with a racquet swing. Most often, the extensor muscles become painful due to tendon breakdown from over-extension. Improper form or movement allows for power in a swing to rotate through and around the wrist – creating a moment on that joint instead of the elbow joint or rotator cuff. This moment causes pressure to build impact forces to act on the tendon causing irritation
and inflammation.
The following speculative rationale is offered by proponents of an overuse theory of etiology: The extensor carpi radialis brevis has a small origin and does transmit large forces through its tendon during repetitive grasping. It has also been implicated as being vulnerable during shear stress
during all movements of the forearm.
While it is commonly stated that lateral epicondylitis is caused by repetitive microtrauma
/overuse, this is a speculative etiological theory with limited scientific support that is likely overstated. Other speculative risk factors for lateral epicondylitis include taking up tennis later in life, unaccustomed strenuous activity, decreased mental chronometry
and speed and repetitive eccentric contraction of muscle (controlled lengthening of a muscle group).
Other ways to prevent tennis elbow:
performs a battery of tests in which pressure is placed on the affected area while the patient is asked to move the elbow, wrist, and fingers. X-rays are used to confirm and distinguish possibilities of existing causes of pain that are not related to Tennis Elbow, such as fracture
or arthritis
. Medical ultrasonography
and magnetic resonance imaging
(MRI) are other valuable tools for diagnosis but are frequently avoided due to the high cost. MRI screening can confirm excess fluid and swelling in the affected region in the elbow, such as the connecting point between the forearm bone and the extensor carpi radialis brevis.
The diagnosis is made by clinical signs and symptoms, which are both discrete and characteristic. With the elbow fully extended, there are points of tenderness over the affected point on the elbow, which is the origin of the extensor carpi radialis brevis muscle from the lateral epicondyle (extensor carpi radialis brevis origin). There will also be pain with passive wrist flexion and resistive wrist extension (Cozen's test
).
Depending upon the severity and quantity of multiple tendon injuries that are built up, the extensor carpi radialis brevis may not be fully healed by conservative treatment. Nirschl has defined four stages of lateral epicondylitis, showing the introduction of permanent damage beginning at Stage 2.
Evidence suggests that joint mobilization
with movement directed at the elbow resulted in reduction in pain and improved function. Positive results have been found with manipulative therapy directed at the cervical spine, although data regarding long-term effects were limited. Low level laser therapy administered at specific doses and wavelengths directly to the lateral elbow tendon insertions offers short-term pain relief and less disability in LET, both alone and in conjunction with an exercise regimen.
s (NSAIDs) to relieve lateral elbow pain in the short term, however there were no improvements found in functional outcomes. Injected NSAIDs were suggested to be better than oral NSAIDs. There was insufficient evidence to recommend or discourage the use of oral NSAIDs.
Corticosteroid
injection are effective in the short term however are of little benefit after a year compared to a wait and see approach. Complications from repeated steroid injections include skin problems such as hypopigmentation
and fat atrophy leading to indentation of the skin around the injection site.
Botulinum toxin
type A to paralyze the common extensor origin chronic tennis elbow that has not improved with conservative measures.
Playing time is one factor in tennis elbow occurrences. However, an increased incidence with increased playing time is statistically significant for only respondents under the age of 40. Individuals over the age of 40 who played over 2 hours, had a 2-fold increase in chance of injury. Those under 40 had a 3.5 times increase compared to those who played less than 2 hours per day.
Tennis
Tennis is a sport usually played between two players or between two teams of two players each . Each player uses a racket that is strung to strike a hollow rubber ball covered with felt over a net into the opponent's court. Tennis is an Olympic sport and is played at all levels of society at all...
and other racquet sports, though the injury
Injury
-By cause:*Traumatic injury, a body wound or shock produced by sudden physical injury, as from violence or accident*Other injuries from external physical causes, such as radiation injury, burn injury or frostbite*Injury from infection...
can happen to almost anyone.
Tennis elbow is an overuse injury occurring in the lateral side of the elbow region, but more specifically, occurs at common extensor tendon
Common extensor tendon
The common extensor tendon is a tendon shared by a number of extensor muscles in the forearm. It attaches to the lateral epicondyle of the humerus....
that originates from the lateral epicondyle
Lateral epicondyle
Lateral epicondyle can refer to:* Lateral epicondyle of the humerus * Lateral epicondyle of the femur...
. While the common name tennis elbow suggests that people who play tennis may develop this condition, other activities of daily living
Activities of daily living
Activities of Daily Living is a term used in healthcare to refer to daily self-care activities within an individual's place of residence, in outdoor environments, or both...
may also cause it.
Data
Data
The term data refers to qualitative or quantitative attributes of a variable or set of variables. Data are typically the results of measurements and can be the basis of graphs, images, or observations of a set of variables. Data are often viewed as the lowest level of abstraction from which...
was collected from 113 patients who had tennis elbow and the main factor between them all was overexertion. Sportspersons as well as those who used the same repetitive motion for many years, especially in their profession, suffered from tennis elbow. It was also common in individuals who performed motions they were unaccustomed to. The data also mentioned that the majority of patients suffered tennis elbow in their right arms.
Other descriptions for tennis elbow are lateral epicondylosis, lateral epicondylalgia, or simply lateral elbow pain
Pain
Pain is an unpleasant sensation often caused by intense or damaging stimuli such as stubbing a toe, burning a finger, putting iodine on a cut, and bumping the "funny bone."...
.
Lateral epicondylitis is a painful condition at the lateral epicondyle of the humerus. The acute pain that a person might feel occurs as one fully extends the arm. Since the pathogenesis
Pathogenesis
The pathogenesis of a disease is the mechanism by which the disease is caused. The term can also be used to describe the origin and development of the disease and whether it is acute, chronic or recurrent...
of this condition is still unknown, an appropriate name is still in the works. Despite the term being tennis elbow, tennis players make up a small number of individuals who suffer from this ailment, often found in manual workers, such as builders and waiters. Bowden states that it should be called lateral elbow syndrome
Syndrome
In medicine and psychology, a syndrome is the association of several clinically recognizable features, signs , symptoms , phenomena or characteristics that often occur together, so that the presence of one or more features alerts the physician to the possible presence of the others...
.
Runge is usually credited for the first description in 1873 of the condition. The term tennis elbow was first used in 1883 by Major in his paper "Lawn-tennis elbow".
Signs and symptoms
- Pain on the outer part of elbow (lateral epicondyleLateral epicondyle of the humerusThe lateral epicondyle of the humerus is a small, tuberculated eminence, curved a little forward, and giving attachment to the radial collateral ligament of the elbow-joint, and to a tendon common to the origin of the Supinator and some of the Extensor muscles. In birds, where the arm is somewhat...
). - Point tenderness over the lateral epicondyle – a prominent part of the bone on the outside of the elbow.
- Gripping and movements of the wristWristIn human anatomy, the wrist is variously defined as 1) the carpus or carpal bones, the complex of eight bones forming the proximal skeletal segment of the hand;...
hurt, especially wrist extension and lifting movements. - Activities that use the muscles that extend the wrist (e.g. pouring a pitcher or gallon of milk, lifting with the palm down) are characteristically painful.
- Morning stiffness.
The symptoms associated with tennis elbow are, but are not limited to: radiating pain from the outside of your elbow to your forearm
Forearm
-See also:*Forearm flexors*Forearm muscles...
and wrist, pain during extension of wrist, weakness of the forearm, a painful grip while shaking hands or torquing a doorknob, and not being able to hold relatively heavy items in the hand. The pain is similar to the pain of the condition known as Golfer's elbow
Golfer's elbow
Golfer's elbow, or medial epicondylitis, is an inflammatory condition of the medial epicondyle of the elbow. It is in some ways similar to tennis elbow....
but the latter occurs at the medial side of the elbow.
Causes
During early experiments, it was thought that tennis elbow was primarily caused by overexertion. Studies have shown that trauma such as direct blows to the epicondyle, a sudden forceful pull, or forceful extension have caused more than half of these injuries.One explanation of how tennis elbow may come about is proposed by Cyriax. The theory states that there are microscopic and macroscopic tears between the common extensor tendon and the periosteum
Periosteum
Periosteum is a membrane that lines the outer surface of all bones, except at the joints of long bones. Endosteum lines the inner surface of all bones....
of the lateral humeral epicondyle. An operation conducted in this study showed that 28 out of 39 patients showed tearing at the tendon cuff. Kaplan stated that the radial nerve
Radial nerve
The radial nerve is a nerve in the human body that supplies the upper limb. It supplies the medial and lateral heads of the triceps brachii muscle of the arm, as well as all 12 muscles in the posterior osteofascial compartment of the forearm and the associated joints and overlying skin.It...
was significantly involved in tennis elbow. He noted the constriction
Constriction
Constriction is a method used by various snake species to kill their prey. Although some species of venomous and mildly-venomous snakes do use constriction to subdue their prey, most snakes which use constriction lack venom. The snake initially strikes at its prey and holds on, pulling the prey...
of the radial nerve by adhesions to the capsule of the radiohumeral joint and the short extensor muscle of the wrist. Evidence found that many differed in how they contracted tennis elbow. Disorders such as calcification of the rotator cuff, bicipital tendinitis, or carpal tunnel syndrome
Carpal tunnel syndrome
Carpal Tunnel Syndrome is an entrapment idiopathic median neuropathy, causing paresthesia, pain, and other symptoms in the distribution of the median nerve due to its compression at the wrist in the carpal tunnel. The pathophysiology is not completely understood but can be considered compression...
may increase chances of tennis elbow.
Pathophysiology
The pathophysiologyPathophysiology
Pathophysiology is the study of the changes of normal mechanical, physical, and biochemical functions, either caused by a disease, or resulting from an abnormal syndrome...
of lateral epicondylitis is degenerative. Non-inflammatory, chronic degenerative changes of the origin of the extensor carpi radialis brevis (ECRB) muscle
Extensor carpi radialis brevis muscle
The Extensor carpi radialis brevis is shorter and thicker than the extensor carpi radialis longus. The longus muscle can be found above the distal end of the Extensor carpi radialis brevis.-Origin and insertion:...
are identified in surgical pathology
Pathology
Pathology is the precise study and diagnosis of disease. The word pathology is from Ancient Greek , pathos, "feeling, suffering"; and , -logia, "the study of". Pathologization, to pathologize, refers to the process of defining a condition or behavior as pathological, e.g. pathological gambling....
specimens. It is unclear if the pathology is affected by prior injection of corticosteroid
Corticosteroid
Corticosteroids are a class of steroid hormones that are produced in the adrenal cortex. Corticosteroids are involved in a wide range of physiologic systems such as stress response, immune response and regulation of inflammation, carbohydrate metabolism, protein catabolism, blood electrolyte...
.
Among tennis players, tennis elbow is believed to be caused by the repetitive nature of hitting thousands and thousands of tennis balls which lead to tiny tears in the forearm tendon attachment at the elbow.
The extensor digiti minimi also has a small origin site medial to the elbow which can be affected by this condition. The muscle involves the extension of the little finger
Little finger
The little finger, often called the pinky in American English, pinkie in Scottish English , or small finger in medicine, is the most ulnar and usually smallest finger of the human hand, opposite the thumb, next to the ring finger.-Muscles:There are four muscles that...
and some extension of the wrist allowing for adaption to "snap" or flick the wrist – usually associated with a racquet swing. Most often, the extensor muscles become painful due to tendon breakdown from over-extension. Improper form or movement allows for power in a swing to rotate through and around the wrist – creating a moment on that joint instead of the elbow joint or rotator cuff. This moment causes pressure to build impact forces to act on the tendon causing irritation
Irritation
Irritation or exacerbation, in biology and physiology, is a state of inflammation or painful reaction to allergy or cell-lining damage. A stimulus or agent which induces the state of irritation is an irritant...
and inflammation.
The following speculative rationale is offered by proponents of an overuse theory of etiology: The extensor carpi radialis brevis has a small origin and does transmit large forces through its tendon during repetitive grasping. It has also been implicated as being vulnerable during shear stress
Shear stress
A shear stress, denoted \tau\, , is defined as the component of stress coplanar with a material cross section. Shear stress arises from the force vector component parallel to the cross section...
during all movements of the forearm.
While it is commonly stated that lateral epicondylitis is caused by repetitive microtrauma
Microtrauma
Microtrauma is the general term given to small injuries to the body.Microtrauma can include the microtearing of muscle fibres, the sheath around the muscle and the connective tissue. It can also include stress to the tendons, and to the bones . It is unknown whether or not the ligaments adapt like...
/overuse, this is a speculative etiological theory with limited scientific support that is likely overstated. Other speculative risk factors for lateral epicondylitis include taking up tennis later in life, unaccustomed strenuous activity, decreased mental chronometry
Mental chronometry
Mental chronometry is the use of response time in perceptual-motor tasks to infer the content, duration, and temporal sequencing of cognitive operations....
and speed and repetitive eccentric contraction of muscle (controlled lengthening of a muscle group).
Prevention
Another factor of tennis elbow injury is experience and ability. The proportion of players who reported a history of tennis elbow had an increased number of playing years. As for ability, poor technique increases the chance for injury much like any sport. Therefore an individual must learn proper technique for all aspects of their sport. The competitive level of the athlete also affects the incidence of tennis elbow. Class A and B players had a significantly higher rate of tennis elbow occurrence compared to class C and novice players. However, an opposite, but not statistically significant, trend is observed for the recurrence of previous cases, with an increasingly higher rate as ability level decreases.Other ways to prevent tennis elbow:
- Decrease the amount of playing time if already injured or feel pain in outside part of elbow
- Stay in overall good physical shape
- Strengthen the muscles of the forearm (Pronator quadratusPronator quadratusPronator quadratus is a square shaped muscle on the distal forearm that acts to pronate the hand.As it is on the anterior side of the arm, it is innervated by a branch of the median nerve, the anterior interosseous nerve...
, Pronator teres and Supinator muscleSupinator muscleIn human anatomy, the supinator is a broad muscle in the posterior compartment of the forearm, curved around the upper third of the radius. Its function is to supinate the forearm.-Terminology:...
), the upper arm (bicepsBicepsBiceps may refer to:*Biceps brachii muscle, a muscle located on the inside of the upper arm*Biceps femoris muscle, one of the hamstring muscles of the back of each thigh*Biceps , a point in a metrical pattern...
, triceps, Deltoid muscleDeltoid muscleIn human anatomy, the deltoid muscle is the muscle forming the rounded contour of the shoulder. Anatomically, it appears to be made up of three distinct sets of fibers though electromyography suggests that it consists of at least seven groups that can be independently coordinated by the central...
), the shoulderShoulderThe human shoulder is made up of three bones: the clavicle , the scapula , and the humerus as well as associated muscles, ligaments and tendons. The articulations between the bones of the shoulder make up the shoulder joints. The major joint of the shoulder is the glenohumeral joint, which...
and upper back (trapezius) - Increased muscular strength will increase the stability of joints such as the elbow
- Like other sports, use equipment appropriate towards your ability, body size and muscular strength.
Diagnosis
To diagnose tennis elbow, the physicianPhysician
A physician is a health care provider who practices the profession of medicine, which is concerned with promoting, maintaining or restoring human health through the study, diagnosis, and treatment of disease, injury and other physical and mental impairments...
performs a battery of tests in which pressure is placed on the affected area while the patient is asked to move the elbow, wrist, and fingers. X-rays are used to confirm and distinguish possibilities of existing causes of pain that are not related to Tennis Elbow, such as fracture
Fracture
A fracture is the separation of an object or material into two, or more, pieces under the action of stress.The word fracture is often applied to bones of living creatures , or to crystals or crystalline materials, such as gemstones or metal...
or arthritis
Arthritis
Arthritis is a form of joint disorder that involves inflammation of one or more joints....
. Medical ultrasonography
Medical ultrasonography
Diagnostic sonography is an ultrasound-based diagnostic imaging technique used for visualizing subcutaneous body structures including tendons, muscles, joints, vessels and internal organs for possible pathology or lesions...
and magnetic resonance imaging
Magnetic resonance imaging
Magnetic resonance imaging , nuclear magnetic resonance imaging , or magnetic resonance tomography is a medical imaging technique used in radiology to visualize detailed internal structures...
(MRI) are other valuable tools for diagnosis but are frequently avoided due to the high cost. MRI screening can confirm excess fluid and swelling in the affected region in the elbow, such as the connecting point between the forearm bone and the extensor carpi radialis brevis.
The diagnosis is made by clinical signs and symptoms, which are both discrete and characteristic. With the elbow fully extended, there are points of tenderness over the affected point on the elbow, which is the origin of the extensor carpi radialis brevis muscle from the lateral epicondyle (extensor carpi radialis brevis origin). There will also be pain with passive wrist flexion and resistive wrist extension (Cozen's test
Cozen's test
Cozen's test is a physical examination performed to evaluate for tennis elbow. It's said positive if a resisted wrist extension triggers pain to the patient. The test is performed with extended elbow....
).
Depending upon the severity and quantity of multiple tendon injuries that are built up, the extensor carpi radialis brevis may not be fully healed by conservative treatment. Nirschl has defined four stages of lateral epicondylitis, showing the introduction of permanent damage beginning at Stage 2.
- Inflammatory changes that are reversible
- Nonreversible pathologic changes to origin of the extensor carpi radialis brevis muscle
- Rupture of ECRB muscle origin
- Secondary changes such as fibrosis or calcification.
Treatment
Evidence for the treatment of lateral epicondylitis is poor. There are clinical trials addressing many of these proposed treatments, but the quality of the trials is poor. In some cases, severity of tennis elbow symptoms mend without any treatment within six to twenty-four months. However, if tennis elbow is left untreated, it can lead to chronic pain that degrades quality of daily living.Physical
There are several recommendations regarding prevention, treatment, and avoidance of recurrence that are largely speculative including stretches and progressive strengthening exercises to prevent re-irritation of the tendon and other exercise measures.Evidence suggests that joint mobilization
Joint mobilization
Joint mobilization is a type of passive movement of a skeletal joint. It is usually aimed at a 'target' synovial joint with the aim of achieving a therapeutic effect...
with movement directed at the elbow resulted in reduction in pain and improved function. Positive results have been found with manipulative therapy directed at the cervical spine, although data regarding long-term effects were limited. Low level laser therapy administered at specific doses and wavelengths directly to the lateral elbow tendon insertions offers short-term pain relief and less disability in LET, both alone and in conjunction with an exercise regimen.
Medication
Topical non-steroidal anti-inflammatory drugNon-steroidal anti-inflammatory drug
Nonsteroidal anti-inflammatory drugs, usually abbreviated to NSAIDs or NAIDs, but also referred to as nonsteroidal anti-inflammatory agents/analgesics or nonsteroidal Anti-inflammatory medicines , are drugs with analgesic and antipyretic effects and which have, in higher doses, anti-inflammatory...
s (NSAIDs) to relieve lateral elbow pain in the short term, however there were no improvements found in functional outcomes. Injected NSAIDs were suggested to be better than oral NSAIDs. There was insufficient evidence to recommend or discourage the use of oral NSAIDs.
Corticosteroid
Corticosteroid
Corticosteroids are a class of steroid hormones that are produced in the adrenal cortex. Corticosteroids are involved in a wide range of physiologic systems such as stress response, immune response and regulation of inflammation, carbohydrate metabolism, protein catabolism, blood electrolyte...
injection are effective in the short term however are of little benefit after a year compared to a wait and see approach. Complications from repeated steroid injections include skin problems such as hypopigmentation
Hypopigmentation
Hypopigmentation is the loss of skin color. It is caused by melanocyte or melanin depletion, or a decrease in the amino acid tyrosine, which is used by melanocytes to make melanin.-Treatments:...
and fat atrophy leading to indentation of the skin around the injection site.
Botulinum toxin
Botulinum toxin
Botulinum toxin is a protein produced by the bacterium Clostridium botulinum, and is considered the most powerful neurotoxin ever discovered. Botulinum toxin causes Botulism poisoning, a serious and life-threatening illness in humans and animals...
type A to paralyze the common extensor origin chronic tennis elbow that has not improved with conservative measures.
Prognosis
Response to initial therapy is common, but so are relapse (18% to 50%) and/or prolonged, moderate discomfort (40%).Epidemiology
In tennis players, about 39.7% have reported current or previous problems with their elbow. Less than one quarter (24%) of these athletes under the age of 50 reported that the tennis elbow symptoms were "severe" and "disabling." While 42% over 50 identified severe and disabling symptoms. More women (36%) than men (24%) considered their symptoms to be severe and disabling. Tennis elbow is more prevalent in individuals over 40, where there is about a 4-fold increase among men and 2-fold increase among women. Tennis elbow equally affects both sexes and although men have a marginally higher overall prevalence rate as compared women, this is not consistent within each age group, nor is it a statistically significant difference.Playing time is one factor in tennis elbow occurrences. However, an increased incidence with increased playing time is statistically significant for only respondents under the age of 40. Individuals over the age of 40 who played over 2 hours, had a 2-fold increase in chance of injury. Those under 40 had a 3.5 times increase compared to those who played less than 2 hours per day.