Tennis elbow
Tennis elbow affects the lateral side of the elbow

Definition

Tennis elbow refers to pathology of the extensor tendon located on the outer side of the elbow causing significant pain. The medical term is 'lateral epicondylitis’. It is most frequent in tennis players, explaining the common name of this pathology. 

Image showing the diseased extensor tendon in tennis elbow

Pathology

Lateral epicondylitis, or tennis elbow, affects the muscles and tendons of the elbow that are used to extend the forearm. The forearm tendons, named extensors attach the muscles to the humerus and specifically to the lateral epicondyle. The main tendon involved in tennis elbow is called the extensor carpi radialis brevis. It functions by extending the wrist joint and grasping with the wrist extended (typical movements when using the tennis racquet in backhand). The exact pathophysiology of tennis elbow is unclear but it is thought to begin with small tears to the origin of the extensor carpi radialis brevis but can also involve the extensor carpi radialis longus as well as extensor carpi ulnaris. These tears cause local proliferation of cells named fibroblasts and formation of scar tissue in the tendon, which becomes inflamed, fibrotic and swollen. This pathophysiological mechanism is called tendinosis. These changes in the tendon are the result of overuse and repetitive movements.

Inflammation of the lateral elbow

Classification

According to Nirschl the pathology of tennis elbow can be divided in four stages:

Stage 1 - reversible inflammatory changes

Stage 2 - non-reversible pathologic changes to the insert of the extensor carpi radialis brevis muscle

Stage 3 - rupture of the extensor carpi radialis brevis muscle origin

Stage 4 - secondary changes such as fibrosis and calcification

Associated injuries

Lateral epicondylitis can arise in combination with other tendon-related conditions such as De Quervain’s tenosynovitis, medial epicondylitis and carpal tunnel syndrome. Occasionally it is found concomitant with inflammation of the:

Radial nerve entrapment (radial tunnel syndrome in 5% patients)

Radial humeral bursa

Synovium

Periosteum

Annular ligament

Left: Distal radius intraarticular, displaced fracture; Middle: Older distal radius fracture with callus formation; Right: Distal radius and ulna fracture, extraarticular and displaced

No 2.

Intra-articular fracture extends to the wrist joint (or articulation)

Extra-articular fracture is located outside of the wrist joint

Open fracture when bone fragments perforate the skin

Comminuted fracture when the bone breaks into multiple fragments

Non-displaced when the anatomical alignment of the bone is maintained or displaced when the bone fragments move apart.

Melone’s classification describes the characteristics of intra-articular fractures of the radius:

i    Stable fracture

ii    Unstable "die-punch"

iii   "Spike" fracture

iv Split fracture

v   Explosion injuries

Acetabular fracture of the pelvis

Acetabular fractures

These fractures are divided into:

Anterior pillar (not weight bearing part of joint)

Posterior pillar (often associated with dislocation of the hip including the weight bearing part of joint)

Transverse

Comminuted involving both column type 

Sacral / coccygeal fractures

The sacrum is a triangular-shaped bone formed by 5 fused vertebrae, which provide a posterior wall to the pelvic ring. At each side of the sacrum, the ala structures articulate with the ilium bones forming the sacro-iliac joints. Sacral fractures are usually parallel to the spine and can involve the ala. Less frequently sacral fractures may display an “H” shape, including a transversal fracture uniting both sides of the sacrum. Three zones are described where sacral fractures can occur that are along vertical lines relative to the alignment of the foramina. Sacral fractures may result in sacral instability and require treatment via sacroplasty (injection of bone glue into the fracture). Surgery is necessary in case of associated neurological symptoms.

Fractures of the coccyx involve the tailbone, the terminal portion of the spine situated below the sacrum formed by 3 to 5 fused vertebrae. Coccyx fractures occur when falling on a seated position. They are more common in elderly women and seldom require surgical treatment.

Tennis is the most common cause of tennis elbow

Causes

Tennis elbow is mostly due to repetitive use of those movements that are commonly executed in playing tennis. It has an incidence of 50% in tennis players and occurs more frequently in individuals between 40-50 years of age. Lateral epicondylitis can also develop in other activities involving the frequent use of the elbows and wrists such as labourers (plumbers, painters, gardeners and carpenters) and computer users due to improper use of the keyboard.

Repetitive movements such as painting may lead to tennis elbow

Risk factors

A number of recreational sports and professions performing rigorous daily activities may increase the risk of acquiring tennis elbow such as:

Racquet sports

Throwing sports

Muscle weakness

Poor flexibility of the forearm

Training errors

Improper technique

Wrong equipment

Occupations involving repetitive wrist extension (carpenters, bricklayers, tailors, pianists, drummers, computer users, typists)

Pain over the later side is typical of tennis elbow

Symptoms

The typical symptoms of tennis elbow include pain to the lateral side of the elbow, which may radiate to the forearm and wrist. Pain increases with wrist extension and supination and subsides with rest. Occasionally the pain can be felt to the arm, postero-laterally. As a consequence of lateral epicondylitis the patient may develop weakening of grip strength.

Ultrasound image of the extensor tendon of the elbow

Diagnosis

Lateral epicondylitis is primarily diagnosed by clinical examination. The patient’s history of sport or profession involving physical activities posing a risk for this pathology and past injuries will be discussed with the examiner. Clinical investigation focuses on the characteristics of pain at rest and during activity such as handshake and gripping. Palpation of the elbow anteriorly, medially, and posteriorly is performed to rule out any other disorder(s). Lateral palpation is used to detect for tenderness directly to the anterior inferior aspect of the epicondyle. The level of pain is assessed with resisted wrist extension. The possible involvement of the radial nerve is manifested by tenderness at touch. Chair raise test is often employed to determine the reduction in muscle strength and pain induced when raising the body keeping the arms extended and the wrists flexed. The examiner will also assess other pathologies including cervical radiculopathy, medial epicondylitis (Golfer’s elbow), radial nerve entrapment).

X-rays are only taken to exclude arthritis to the radio-capitellar joint or other bone-related conditions (osteophytes on the lateral epicondyle) and to visualise calcium deposits in the tendon.

Ultrasound is often sufficient to detect changes in the structure of the tendon including the presence of tears and swelling. MRI is performed seldom, when diagnosis is unclear and subtle changes of the bones and soft tissues may have not revealed with X-rays. Neural involvement is revealed by pain reduction following local injection of anaesthetics.

Treatment

Local injection of steroids is used if symptoms persist

Nonoperative treatment

Conservative treatment for lateral epicondylitis is successful in 90-95% of patients following a standard regime including:

Rest

Administration of NSAID’s

Splinting

Local injection of steroids

Autologous blood injections

Laser therapy

Extracorporeal shock wave therapy

Botox injection (pain treatment)

Hyaluronate injections

Physical therapy

Incision over the lateral epicondyle to repair the torn extensor tendon

Surgical treatment

If symptoms do not improve after 6 to 12 months of conservative treatment surgery is recommended. This involves the debridement or removal of the tendon segment with evident tendinosis. This is followed by the reattachment of the extensor tendon to the bone.

Surgery is achieved more frequently via open surgery through an incision over the elbow or arthroscopic surgery, which is a less invasive approach due to the reduced external access to the elbow.

Elbow braces protects the injured tendons at the elbow

Rehabilitation

Rehabilitation for a tennis elbow focuses on physical exercises to strengthen the muscles of the forearm and increase their flexibility through regular stretching. Additional rehabilitative therapy include:

Ultrasound, ice, massage or muscle stimulating techniques to improve muscle healing

Use of braces supports the muscle and relieves pain

After surgery the elbow is immobilised with a splint for about one week after which rehabilitation can commence. Physical therapy include initial stretching to restore muscle and tendon flexibility followed by more vigorous workout 2 months after surgery.

Sport activities can be resumed 4-6 months from the diagnosis. Physical exercise is critical for the treatment of tennis elbow, whether operated or not, and offers a variety of approaches:

Rest

Ice or heat

Taping or bracing during sport

Ice application

Soft tissue massage

Electric stimulation

Ultrasound

Joint mobilisation

Progressive exercises to improve flexibility and strength

Postural correction

Physical exercise helps to strenghten the elbow muscles

Prevention

Introducing simple measures when practicing sport or other physical activities can help preventing a tennis elbow. Changing the characteristics of racquets with looser-strings, smaller, lighter and with smaller grips can reduce the stress on the forearm muscles and prevent recurrent tennis elbow.

Other recommendations include:

Use of taping, straps to minimise forearm muscle strain

Stretching exercises before and after practicing tennis/other sports

Warm up before sport

Patient education, activity modification

Avoid weight lifting

Ergonomic assessment of workplace

Maintain muscle strength with regular exercise