The Wimbledon Effect Series: Tennis Elbow

In the second instalment of our Wimbledon Effect blogs we will be looking at tennis elbow, probably the foremost injury that comes to mind when we think of upper-limb tennis injuries. We’ll be addressing:

  • What is tennis elbow?
  • What causes tennis elbow?
  • How we treat tennis elbow?

What is tennis elbow 

Tennis elbow (also known as lateral epicondylitis) is primarily the overuse of a muscle called extensor carpi radialis bravis (ECRB). This muscle starts at the outside of your elbow (the lateral epicondyle) and passes over your wrist and middle finger, which allows you to lift your wrist and middle finger backward.

Research shows that overuse of your ECRB causes thickening in the connective tissues in an unstructured manner and irritates the surrounding nerves, rather than inflammation as previously thought (De Smelt et al., 2007). When identifying tennis elbow, you will often notice pain on palpation around the outside of elbow, and on resisted wrist and middle finger extension. Depending on the duration of symptoms, it reduces strength in the forearm muscles that pull your wrist back and assist with gripping.

What causes tennis elbow in tennis players?

You will be surprised to find out that the prevalence of tennis elbow is higher in recreational tennis players compared with elite. This can be due to a number of reasons, but one major difference is the quantity of time playing tennis.

When looking at recreational players, they suddenly influx in playing during the summer months due to the Wimbledon effect after no tennis during the winter period. This is the equivalent to deciding to attend the gym again after 3 months non-activity and attempting to bench press 100kg 3 days in a row in preparation for the beach. Your muscles are going to be sore and possibly sustain injuries as they are not used to this level of training or being used for long periods in sequential days. For elite players, over the years the number of grand slams and tour locations has increased globally, which has meant they only get a rest period of a month, in December. This has resulted in a different type of over training, and having insufficient time to recover between tournaments, especially when travelling long distance between venues.

tennis-elbow-game

Differences in stroke technique can be a contributing factor as the ECRB muscle is used in all tennis strokes; if you have a poor technique it can lead to greater activity of the wrist extensors (Morris et al.,1989).This is particularly evident when playing backhand with a one-handed technique, as two-handed stroke’s non-dominant arm absorbs more energy and changes the mechanics of the swing (Giangarra et al, 1993). Research has shown that the optimum wrist position is to maintain it extended to about 23° from neutral alignment, with the wrist moving further into extension at impact. This is demonstrated in elite players, and their ability to reduce impact transmission from the racquet to the wrist and elbow (De Smedt et al., 2007) reducing the likelihood of tennis elbow.

The novice players maintain their wrist in a flexed position during backhand stroke, this results in overloading their wrist extensor muscles throughout the stroke, which can contribute to tennis elbow (Blackwell and Cole, 1994). They also demonstrated this flexed position during ball impact and early follow-through. Therefore when teaching novice players to hold their racquet correctly, it is described to them to hold it like they are using a hammer.

tennis-elbow-racket-wrong
tennis-elbow-racket-right

Tennis elbow symptoms can also arise due to nerve irritation of the posterior interosseus nerve that supplies signals to the ECRB muscle in your forearm. Although this can result in symptoms similar to tennis elbow, it is actually referred pain from the neck into the arm/s.

Factors that have been disregarded as contributing factors to tennis elbow are string vibration, and therefore dampers showed no significant differences in discomfort ratings, and tennis racquet grip size that showed no alteration in forearm muscle firing patterns if the racquet was over or under the recommended grip size of 6.35mm.

How are we treating tennis elbow?

Our treatments for tennis elbow can differ depending on the stage of chronicity.

For acute true tennis elbow, we normally treat with stretching, acupuncture in the first 2-8 weeks, eccentric loading of the ECRB, and strengthening. We would also observe the stroke technique and correct any movement patterns around the shoulder, elbow and wrist that could cause tennis elbow initially and also from returning.

For chronic tennis elbow, once we have exhausted conservative management you may require microtenotomy surgery to the ECRB that has shown good results in reducing pain and increasing functional outcomes in the short and long term (Tasto et al., 2005), or surgery to release the extensor muscles’ tendons at the origin.

With referred pain that is coming from the neck or irritated nerve supplying ECRB (which is not always actually tennis elbow as described above), we will treat this with mobilisation of the facet joints in the neck and/or nerve glide exercises. Additionally we will look at movement patterns that could be contributing to reduced nerve mobility, and stress factors that could be causing increased muscle tension.

Conclusion

When looking at tennis elbow, we first have to identify if it is true tennis elbow, and if so what factors in your tennis could be contributing to overuse of your ECRB. This will ensure that we effectively treat your symptoms and reduce the risk of tennis elbow returning.

If you are suffering with tennis elbow and want to get back on the court before the British summer disappears, why not make an appointment with PhysioMotion Limited on 0203 422 6655. We can help you identify what could be triggering your symptoms and get you playing tennis pain free.

References

1. Morris M, Jobe FW, Perry J, et al. Electromyographic analysis of elbow function in tennis players. Am J Sports Med 1989;17:241–7.

2. De Smedt T, Jong A, Van Leemput W, Lieven D, Van Glabbeek F. Lateral epicondylitis in tennis: update on aetiology, biomechanics and treatment. British Journal of Sports Medicine 2007; 41:816-819.

3. Giangarra CE, Conroy B, Jobe FW, et al. Electromyographic and cinematographic analysis of elbow function in tennis playerss using single- and double-handed backhand strokes. Am J Sports Med 1993;21:394–9.

4. Blackwell JR, Cole KJ. Wrist kinematics differ in expert and novice tennis players performing the backhand stroke: implications for tennis elbow. J Biomech 1994;27:509–16.

5. Tasto JP, Cummings J, Medlock V, et al. Microtenotomy using a radiofrequency probe to treat lateral epicondylitis. Arthroscopy 2005;21:851–60.