Overuse Injuries of the Elbow:

Tennis Elbow (Lateral Humeral Epicondylitis)

Tennis elbow refers to an inflammation of the tendon of the forearm extensor muscles where they insert into the bony knob on the outside of the elbow.

Tennis elbow is one of the most common overuse injuries of all, and is certainly one of the most frequently seen sports injuries of the upper body. According to studies, up to half of tennis players who play every day, and 25 percent of those who step on the court once or twice a week, get this condition. But tennis elbow doesn't just affect tennis players alone. It is also seen in golf and other racket sports, especially squash and racquetball.

Tennis elbow is caused by repetitive stress to the forearm muscles; that stress transmits up to where the muscle tendon inserts into the outer elbow knob, the lateral humeral epicondyle. The stress can be aggravated if the player is not properly conditioned, or if he or she uses improper equipment or inappropriate technique. Often it's a combination of several factors. Faulty backhand techniques (too "wristy" a stroke) are the main culprit when it comes to form. There are a host of external factors that can cause tennis elbow, including:

Racket: the heavier the racket, the smaller the grip, and the tighter the string tension, the more stress on the arm.

Court Surface: hard, fast surfaces - grass and concrete especially - increase the speed at which the ball hits the racket strings, and increase the amount of stress transmitted to the elbow.

Balls: older and heavier balls increase the amount of stress absorbed by the arm.

The risk factor in tennis elbow that is most often overlooked is conditioning, specifically lack of strength and flexibility in the shoulders. A weak shoulder is often the first stage in a sequence of ailments that culminates in tennis elbow. Often the athlete starts off with an irritation of the rotator cuff, which causes weakness in the entire arm. The weakness in the arm may affect technique, which may in turn cause tennis elbow.

Tennis elbow is especially prevalent in the over-forty set because, the older a person gets, the slower the body heals. In middle-aged or older athletes, the micro-tears where the muscle tendon inserts into the outer bony knob of the elbow do not have the time to heal between matches. See below for additional tips on preventing tennis elbow.

Symptoms:

Onset of symptoms is gradual
Pain directly over the outer elbow knob (the lateral humeral epicondyle)
Pain increases when the wrist is rotated against resistance, as in trying to turn a doorknob or shake hands

Cause:

Repetitive stress to the extensor muscles in the forearm that transmits to where the extensor tendon inserts
into the outer elbow knob.

Athletes at Risk:

Primarily racket sports players and golfers.

Concerns:

Tennis elbow needs to be addressed early. Otherwise, scar tissue builds where the muscle tendon inserts into the outer bony knob and makes the condition difficult to alleviate. Because this area heals so poorly (the blood supply here is extremely poor), prevention and early intervention are the keys to management.
If the pain on the bony knob on the outside of the elbow is severe, there may be a complete rupture of the tendon attachment to the lateral numeral epicondyle due to chronic weakening of the structure.

What you can do:

Ice the area as soon as symptoms are felt. Ice massage is an especially effective technique for tennis elbow. Compression and elevation are not necessary because there is no swelling.
After seventy-two hours, use a moist heating pad to promote healing.
Cease all activities that caused the condition until the pain goes away and the cause or causes of the injury have been addressed.

Medication:

For relief of minor to moderate pain, take acetaminophen as directed on label.
For the relief of pain and inflammation, take ibuprofen if tolerated.

What the doctor can do:

A physical examination will confirm the diagnosis of tennis elbow.
X Rays will be taken to rule out other possible causes of pain, such as a fracture or a loose body in the joint. In addition, the doctor should investigate the possibility of other conditions, including rheumatic arthritis, a trapped radial or ulnar nerve, or referred pain from a pinched nerve in the neck.
Surgery is rarely required for tennis elbow. Initial treatment consists of frequent icing and use of anti-inflammatories.
If the condition has been allowed to deteriorate before medical attention is sought, the doctor may give the patient a steroid injection. Steroid injections have proven to be a quick, highly effective means of clearing up the pain from tennis elbow. The injection is made near the point where the muscle tendon inserts into the bony knob on the outside of the elbow, not directly into the tendon. Each injection should be followed by one or two weeks of rest and then a gradual conditioning program. It is not advisable to give more than two to three steroid injections for tennis elbow, as this can weaken the tendon.
If the condition hasn't cleared up after conservative treatment and steroid injections, surgery may be necessary. Surgery involves scraping the scar tissue out, then drilling a hole into the bone to stimulate blood supply. This drilling procedure promotes healing of the tissue. This is not always successful.

Rehabilitation:

The crux of the rehabilitation program for tennis elbow is to develop strength and flexibility in the entire arm, including the shoulder.
Special attention should be paid to strengthening the tendon insertion into the lateral humeral epicondyle.

Recovery Time:

Depending on the extent to which the condition has deteriorated, tennis elbow can take anywhere from between two weeks to a couple of years to heal.
In the case of mild tennis elbow, after addressing the cause of the condition athletes can return to action when the arm has regained full strength and range of motion and there is no pain. In the initial stages though, the activity level should be no more than half of the pre-injury level. This can be increased by 10 percent each session.
After surgery, it may take two to three months before a full playing schedule can be resumed.

PREVENTING TENNIS ELBOW

If you suffer from tennis elbow, review the following possible causes of this condition, consider which may apply to you, and address them before returning to play.

Technique

Your forearm muscles should be used for control, not power. Most of the power should
come from your shoulders, torso, and leg muscles, coordinated with rotation of your hips.

Focus on hitting the "sweet spot" as often as possible.

Follow through on your stroke; don't "brake" after hitting the ball.

Learn proper footwork so you approach the ball correctly.

Equipment

Use a light racket (12-12.5 oz.) made of graphite, which provides good impact absorption.

Use the largest grip that's comfortable. The optimal grip size is the distance from the tip of
your ring finger to the bottom horizontal palm crease at the point between your ring and middle fingers.

To minimize impact, your racket should have an approximate string tension of 52-55 lb. on 16-gauge nylon.

Ensure that the balls you use are not old or wet.

Court Surface

Play on a court with a slower surface, thus reducing the impact of the ball on your racket.

Conditioning

Develop strength and flexibility in the arm, shoulder, and back muscles.

Tennis elbow straps may provide relief from tennis elbow, while at the same time allowing the injury to
recover. However, never use a tennis elbow strap unless you are positive your injury is tennis elbow.
Tennis elbow straps may worsen conditions such as medial elbow instability in adults and growth plate
fractures in children, whose symptoms resemble tennis elbow but require very different treatment.

Conditioning Program for the Elbow

Conditioning to prevent elbow injuries involves improving the strength and flexibility of all major
muscles surrounding the joint, primarily the biceps and triceps of the upper arm an the flexors and
extensors of the forearm.

Exercises to stretch and strengthen the muscles around the elbow often incorporate exercises to improve
flexibility and strength in the shoulder, wrist and hand. Effective conditioning to prevent elbow injures
must also include exercises to improve strength and flexibility in the surrounding joints, especially the shoulder.

Incorporate into your workout at least one set of the following exercises for each muscle group mentioned.

Make these exercises part of an overall strength and flexibility program, and do them before any activity
that will stress the muscles around the elbow.

Elbow Strengthening Exercises

Biceps: Seated dumbbell curl, barbell curl

Triceps: Standing dumbbell triceps extension, bar dips, lying barbell triceps extension

Forearm extensors: Wrist curl, wrist roll

Forearm flexors: Reverse wrist curl, wrist roll

Reprinted with permission from The Sports Medicine Bible (HarperCollins), by Dr. Lyle J. Micheli,
former President of the American College of Sports Medicine