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Tennis Elbow (Lateral Epicondylitis)
Cause of Injury The most widely accepted theories regarding lateral epicondylitis recognize it as an overuse injury. The constant, repetitive motions associated with certain recreational activities and occupations can lead to this chronic condition. Studies have shown that, regardless of the name “tennis elbow”, auto workers, cooks, and butchers are diagnosed with lateral epicondylitis more frequently than the rest of the population. Aside from what occupation/activity the injury is attributed to, the mechanism of injury is generally the same. The extensor carpi radialis brevis (pictured above) helps to stabilize the wrist when the elbow is straightened. When one is repetitively stressing this muscle (i.e. hammering, painting, forehand tennis stroke), microscopic tears occur at the point where the muscle attaches to the lateral epicondyle. These micro-tears cause inflammation and pain, which is generally localized to the lateral elbow. Signs and Symptoms Lateral epicondylitis is a chronic, overuse injury; there is rarely one, specific mechanism of injury associated with the onset of symptoms. The initial signs of injury are usually mild, but gradually worsen over time. The most common signs and symptoms include:
In most cases, lateral epicondylitis develops in one’s dominant arm; however, it is possible for both arms to be affected. Diagnosis A diagnosis can often be determined without extensive testing, such as x-ray and MRI. In most cases, simply getting an accurate patient history (i.e. how the symptoms developed, occupational risk factors, or recreational sport participation) can direct one’s healthcare provider in the right direction. In most cases, one’s range of motion will be normal although severe causes may cause movement restrictions. Upon palpating the involved extremity, tenderness is often noted in the region of the lateral epicondyle (pictured above). Pain may also be experienced when extending the elbow against resistance. Treatment The majority of cases of lateral epicondylitis can be treated via the conservative approach. This treatment generally includes physical therapy, which utilizes a three phase approach. The first phase of therapy consists of rest and the use of non-steroidal anti-inflammatory medication. This portion of therapy will last until the acute pain from the injury subsides. The second phase of physical therapy consists of a stretching program with emphasis on increasing the flexibility of the wrist extensors (pictured above). The initial stretches are performed with the elbow flexed at 90°, followed by gradually straightening the elbow with the stretches. One should not attempt to progress themselves in the stretching program without being instructed to do so by their physical therapist. The final phase consists of a strengthening program. Once full, pain-free range of motion has been achieved, it is crucial to strengthen the forearm muscles throughout that range of motion. It is important to understand that soreness is generally associated with both the second and third phases of treatment. Another technique that has proven to be beneficial is mobilization with movement. The previously mentioned treatment plan may be supplemented with this method to insure that the elbow joint is functioning properly throughout the available range of motion. This technique is not painful and consists of performing flexion and extension of the elbow while the therapist applies force to a specific location on the joint. Some products are available on the market to help relieve pain while performing daily and/or recreational activities. A standard wrist splint that maintains a neutral joint position may have some benefit, but is not intended to be worn during most recreational activities. A forearm clasp brace (pictured below) has been proven to relieve pressure in the forearm extensor muscles, thereby decreasing one’s pain.
Finally, when treating tennis players, it is imperative to consider their form and/or equipment when designing a treatment plan. Often times, improper form (i.e. leading with one’s elbow during a backhand stroke) may lead to irritation at the lateral epicondyle. Simply recommending that the player receive professional lessons to learn the correct technique can relieve their symptoms. Along with improper form, playing with a racquet with the wrong grip size can also induce pain. Using a racquet with too large of a grip can lead to hand pain, whereas too small of a grip can lead to hand, wrist, and elbow pain. Therefore, being measured for the correct size is crucial. To determine your correct grip size, measure from the middle crease of your palm to the tip of your ring finger (see below). The amount of tension in the strings of the racquet may be a precipitating factor, as well. While higher string tension provides increased ball control, it also increases the torque and vibration experienced by the arm. To avoid these unnecessary forces, you should stay at the lower end of the manufacturer’s recommendation for string tension.
References American Academy of Orthopedic Surgeons. Tennis Elbow (Lateral Epicondylitis). September 2009. http://www.orthoinfo.aaos.org American Association for Hand Surgery. Lateral Epicondylitis FAQ. Nicholas Institute of Sports Medicine and Athletic Trauma. Physical Therapy Corner: Tennis Elbow. September 2009. http://www.nismat.org/ptcor/tennis_elbow Noteboom, T. Tennis Elbow: A Review. Journal of Orthopedic and Sports Physical Therapy. 1994; 19(6): 357-366. Vicenzino, B. Development of a clinical prediction rule to identify initial responders to mobilization with movement and exercise for lateral epicondylalgia. Manual Therapy. 2009; 14: 550-554.
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