Tennis elbow

TENNIS ELBOW

I am sure every one is fascinated by tennis. We may not get a place under the sun with Steffi Graff, Monica Seles, Boris Becker and others but certainly we may get an with an orthopedic surgeon for a problem common in them, that too without playing tennis! Yes, the obvious reference is towards tennis elbow .

History

IT was first described from the Writer's cramps by Range in 1873. It was Madris who called it as "tennis elbow" shortly thereafter.

Definition

Painful elbow syndromes encompass lateral, medial and posterior elbow symptoms. The one commonly encountered is the lateral tennis elbow which is known as the classical tennis elbow (Flow chart 19.2) and is the pain and tenderness on the lateral side of the elbow, some well defined and some vague that results from repetitive stress.

Painful Elbow Syndromes

Classical Tennis elbow It is the lateral tennis elbow

Other varieties

Medial painful elbow (Golfer's elbow)

Posterior painful elbow around the margins of the olecranon process

Vital points

Location of pain in tennis elbow

Lateral epicondyle (75%)

Lateral muscle mass (17%)

Medial epicondyle (10%)

Posterior (8%)

LATERAL EPICONDYLITIS OR TENNIS ELBOW It is a lesion affecting the tendinous origin of common wrist extensors from the lateral epicondyle .

Causes

Epicondylitis This is due to single or multiple tears in the common extensor origin, periosteitis, angiofibroblastic proliferation of extensor carpi radialis brevis (ECRB), etc.

Inflammation of adventitious bursa Between the common extensor origin and radio humeral joint.

. Calcified deposits Within the common extensor tendon.

Painful annular ligament is due to hypertrophy of syno vial fringe between the radial head and the capitulum's.

Pain of neurological origin, for example, cervical spine affection, radial nerve entrapment, etc.

Tennis elbow

Tennis elbow is seen in:

All levels of tennis players.

In world class players "SERVE" appears to be the cause.

In less than world class players "backhand stroke". Seen in other sports also.

May be occupational, etc.

Activities other than tennis which lead to tennis elbow:

Tightening a screw

Using a wrench

Wringing washed clothes

Vigorous hand shake

Causes in tennis players More than one-third tennis players all over the world are affected with this problem over 35 years of age.

Novice

Playing several games per week (Fig. 19.37)

> 35 years of age Equal sex incidence

Backhand stroke (38%)

Serve (25%)

Forehand stroke (23%)

Backhand volley (7%) Overhead smash (4%)

Forehand volley (3%)

Household activities causing tennis elbow Different types of Indian household women suffering from tennis elbow (Figs 19.38A to D).

Contributing factors

Little playing experience.

Consistent missing of teweet spot' while hitting.

Poor stroke techniques use of arm instead of body.

Poor power or flexibility.

Heavy stiff racket, large handle size, too tight racket stringing.

Heavy duty wet balls.

е Playing surface-balls bounce quicker off the cement court.

Pathophysiology and Related Symptoms

Stage I There is acute inflammation but no angioblas invasion. Patient complains of pain during activity.

Stage II This is the stage of chronic inflammation. There is some angioblastic invasion. Patient complains of pain both during activity and at rest.

Stage III Chronic inflammation with extensive angioblastic invasion. Patient complains pain at rest, night pains, and pain during daily activities.

Clinical Tests

Local tenderness on the outside of the elbow at the common extensor origin with aching pain in the back of the forearm (Fig. 19.39).

Painful resisted extension of the wrist with elbow in full extension elicits pain at the lateral elbow (Fig. 19.40 Cozen's test).

Elbow held in extension, passive wrist flexion and pronation produces pain.

Treatment

Conservative management It consists of rest and pain killers. In tennis players exercises, light racket, smaller grip, elbow strap, etc. are helpful (Fig. 19.41). Injection of local anesthetic and steroid are useful in 40 percent of cases (Fig. 19.42).

Physiotherapy Management for Tennis Elbow The following measures are used to counter the pain:

During the Acute Phase

Rest An above elbow POP splint with elbow in 90° fle xion and supination and the wrist in slight dorsiflexion is recommended.

Thermotherapy Heat modalities like, ultrasound and SWD help a great deal in reducing pain.

Cryotherapy Ice cold packs on the tender area for a period of 15-20 mts are very effective in reducing the pain.

Electrical stimulation If this is done for 15-20 mts with the arm elevated, it reduces pain and inflammation.

• Massaging gentle massaging for the first 10 days followed

by friction massages for the next 15 days greatly helps. Exercises Active exercises for the shoulder, elbow, wrist and hand are indicated. Isometrics also helps.

Progressive resistive exercises for wrist extension, lateral deviation, forearm supination and finger flexion using the normal contra lateral hand distinctly improves the condition (Dumbbells of 0.5 to 2 kg are used).

Manipulation This is practiced in certain situations and is not commonly done.

Injection treatment Local infiltration of hydrocortisone is an effective method in certain resistant cases.

Postacute Phase

Patient is instructed to avoid repeated wrist extension and supination movements.

Strengthening exercises to the extensor carpi radialis longus and brevis muscle, supinator muscle and common extensor group of muscles after adequate period of rest and support during the acute phase.

Passive exercises In the supine position, relaxed passive movements of the elbow flexion and forearm supination are carried out in its complete range.

Resistive exercises When a painless range of move ments are achieved by the passive exercises, progressive resistive exercises are advised.

Strengthening exercises Strong isometric exercises to the triceps, active ROM, exercises to the wrist and fingers are also advised.

Surgical Management

Indications

Severe pain for 6 weeks at least.

Marked and localized tenderness over lateral epicondyle.

Failure to respond to restricted activity or immobilization for at least 2 weeks.

Surgical Methods

Percutaneous release of epicondylar muscles.

Bosworth technique of excision of the proximal portion of the annular ligament, release of the origin of the extensor muscles, excision of the bursa and excision of synovial fringes.

Arthroscopic release of the common extensor muscles origin from the lateral epicondyle is the surgical method of choice due to its minimal exposure and effectiveness.

Physiotherapy after Surgery

Measures to control pain as mentioned earlier.

Active ROM exercises to the shoulder

Passive ROM exercises to shoulder, elbow, forearm and wrist.

Progressive RE as mentioned earlier.

Thermotherapy helps to reduce pain.