Tennis elbow: Basic overview

 

Ref: https://uniquephysio.com.au/

Thanyapura resort is one of the most popular places for tennis players in Phuket. There are 6 tennis courts and Thanyapura unique team coaches that entice many tennis players to visit us. It is possible to see some players with tennis elbow want to see a physiotherapist which is one of Thanyapura medical services to treat and maintain their tennis package.

So, tennis elbow is one of the most common injuries which come and see me to treat. Some of them have got chronic pain, and some of them have acute pain. Patients complain of an area of pain and tenderness over the bony prominence of the lateral elbow which is epicondyle. 

Lateral epicondyle of elbow is on thumb side
(Ref: https://strivept.ca/tennis-elbow/)

Tennis elbow is an overuse injury that is common in racket sports. It was first described by Runge1 in 1873 and eventually given the label ‘Lawn Tennis Arm’ by Henry Morris, writing in the Lancet in 1882. 

Tennis elbow is a misnomer as it is predominantly seen in non - tennis players ;however, elbow pain is encountered in up to 50%of tennis players, with 75–80% of these cases being attributable to tennis elbow. Some patients answered my subjective exam that they did not get this pain during playing tennis, for example, hand the luggage during traveling, gardening, cooking, wring the clothes.

  

Squash backhand swing performs wrist extension
(Ref: https://squashmad.com/)

The background has not been well identified. However, it is commonly associated with repetitive microtrauma from excessive gripping or wrist extension, radial deviation, and/or forearm supination. Repetitive microtrauma resulting from overload or overuse can cause collagen fibril rupture and the activation of the innate immune system. 

There is a wide spectrum of severity ranging from slight tenderness to severe, continuous pain. Pain is characteristically exacerbated by resisted extension of the middle finger and also by extension of the wrist, associated with resisted wrist and finger extension and gripping activities. 

Too tight griping and wrist thumb side bending as radial deviation is one of the mechanism of tennis elbow
(Ref: https://msspc.org/)

Anatomy of tennis elbow pain

Patients complain of an area of pain and tenderness over the bony prominence of the lateral aspect of the elbow. This structure is also the common origin of the long extensor tendons for the forearm and hand and the underlying pathology appears to be an area of degenerative change within these tendons. 

The extensor carpi radialis longus

The extensor carpi radialis longus originates from the supracondylar ridge below the origin of the brachioradialis. This attachment is between the brachialis medially and the extensor carpi radialis brevis inferolaterally. The extensor carpi radialis longus crosses the elbow and carpal joint to insert onto the dorsal base of the second metacarpal and is covered by the brachioradialis over most of the forearm. Its function is that of wrist extension, radial deviation, and possibly elbows flexion. 

Extensor Carpi Radialis Longus (ECRL)
Ref: https://www.kenhub.com/en/)

    The extensor digitorum communis

The extensor digitorum communis originates from the anterior distal aspect of the lateral epicondyle and accounts for most of the contour of the extensor surface. Parts of the extensor digitorum communis are also attached to the septum and tendon from which the extensor carpi radialis brevis arises. The extensor digitorum communis insertion contributes to the extensor mechanism for the index, long, ring, and little fingers. In addition to the extension of the wrist and the digits. Wright et al., suggests that the extensor digitorum communis may assist with elbow flexion when the arm is in pronation. 

Extensor Digitorum Communis
(Ref: https://www.orthobullets.com/anatomy/)

The extensor carpi radialis brevis (ECRB)

“The extensor carpi radialis brevis (ECRB) is the most frequently affected muscle.”

 

Extensor Carpi Radialis Brevis (ECRB) Ref: https://quizlet.com/

 

             The extensor carpi radialis brevis is covered by the extensor carpi radialis longus and its fibers are almost indistinguishable from those of the extensor carpi radialis longus and extensor digitorum communis in most cases. The extensor carpi radialis brevis muscle also has additional attachment to the radial collateral ligament and the intermuscular septa between it and common extensor muscle. The extensor carpi radialis brevis tendon inserts to the dorsal surface of the base of the metacarpal bone. The unique origin of ECRB in the lateral aspect of the capitellum places the tendon at risk for repeated undersurface abrasion during elbow extension and flexion that are the factor of excessive mechanical forces. 

The main function of the ECRB is pure wrist extension with some assisted radial deviation. 

Therefore, the pronator and other extensor carpal muscles are also commonly affected.

Mechanism of injury

Tennis elbow may be believed to be the cause from activities such as tennis, badminton or squash but is also common after periods of excessive wrist use which is often caused by overuse or repetitive strain caused by repeated extension (bending back) of the wrist against resistance.

The exact origin has not been well identified. However, it is commonly associated with repetitive microtrauma from excessive gripping or wrist extension, radial deviation, and/or forearm supination that are the function of 3 muscles as above. By the way, the extensor carpi radialis brevis (ECRB) is the most frequently affected muscle that the factor of excessive mechanical forces, the unique origin of ECRB in the lateral aspect of the capitellum places the tendon at risk for repeated undersurface abrasion during elbow extension and flexion. 

Wrist function 
(Ref: https://www.revolutionarytennis.com/)

Although, tennis elbow was originally considered as an inflammatory process, especially in its initial phases. Repetitive microtrauma resulting from overload or overuse can cause collagen fibril rupture and the activation of the innate immune system. However, histopathological studies have shown that there is absence of inflammatory cells in biopsies of chronic epicondylitis.

When it becomes tendinosis, a symptomatic degenerative process characterized by an abundance of fibroblasts, vascular hyperplasia, and unstructured collagen. These findings were termed as angiofibroblastic hyperplasia. The mechanical properties of tendons are commonly determined by the structure of protein molecules and the composition of the extracellular matrix.

Poor forehand alignment ball impact can develop tennis elbow as well
(Ref: https://www.patcash.co.uk/)

The main cause of tennis elbow is degeneration, additional pathophysiological mechanisms also contribute to the development of tendinosis. Patients with painful symptoms often involuntarily lead to “underuse” or stress shielding of affected tendons, which subsequently results in structural weakening of the tendon, making it more sensitive to injury. Meanwhile, increasing shear forces promotes fibrocartilaginous formation at tendon enthesis, which contributes to weakening at the tendon-bone junction and initiating development of tendinosis. 

In situations of repetitive stretching, multiple microtears of the tendon potentially cause an irreversible denaturation of matrix proteins and proliferation of fibrous tissue. Over time, these scar tissues are vulnerable to repetitive forces, with subsequent further tears. High - frequency cyclical trauma and immature repair result in more severe tears, with consequent alteration and failure of musculotendinous biomechanics and worsening of symptoms. Emerging evidence indicates a significant link between the strain degree of tendons and the extent of injuries.

Ref: https://www.kachathailand.com/

Injury rate is equally common among men and women, occurs more frequently among whites and in the dominant arm, and increases with age, peaking between the ages of 30 and 50, with a mean age 42. It seems to occur equally among blue-collar and white-collar workers and among socioeconomic classes. The natural course of the condition seems to be favorable, with spontaneous recovery within 1–2 years in 80–90% of the patients.

“Not only racket sports activities gripping develop tennis elbow including; (1) A poor backhand technique in tennis. (2) A racket grip that is too small. (3) Strings that are too tight. (4) Playing with wet, heavy balls, but also common after periods of excessive wrist use in day-to-day life and it may be caused through repetitive activities such as using a screwdriver, painting or typing.”

 

Very tight hammer working as very tight grip

Clinical  presentation & Diagnosis

Pain around the lateral epicondyle is known by a variety of names, and was described as periostitis, extensor carpi radialis brevis (ECRB) tendinosis and epicondylagia. The most commonly used names are “tennis elbow” and “lateral epicondylitis”. The use of the terms ``periostitis” and “epicondylitis” was questioned over time, as histological studies failed to show inflammatory cells (macrophages, lymphocytes and neutrophils) in the affected tissues. 

The onset of pain is usually gradual. The tenderness is most notable at the anterior aspect of the lateral epicondyle and the lateral forearm that above the epicondyle will indicate that the extensor carpi radialis longus is involved, while anterolateral tenderness would arise from extensor carpi radialis brevis tissue inflammation. Palpation of the radial collateral ligament may elicit exquisite tenderness and is usually increased with varus (adduction) stress to the elbow.

Tenderness point of tennis elbow
(Ref: https://www.sportsinjuryclinic.net/)

Swelling or ecchymosis is rare, except in cases of external trauma. The arm is painless at rest and during passive range of motion. In most cases, the lesion will involve the junctional tissue at the common extensor muscle origin of the lateral epicondyle, specifically, the extensor carpi radialis brevis. If the extensor carpi radialis brevis is involved, extension of the wrist will be more painful if resistance is given at the heads of the metacarpals rather than at the fingertips. Radial extension will more specifically indicate the extensor carpi radialis brevis or extensor carpi radialis longus. Pain with resisted extension of the middle finger is present when the extensor carpi radialis brevis is involved. Grip strength may be decreased by pain. 

Swelling in tennis elbow
(Ref: https://www.scripps.org/)

Diagnosis of tennis elbow may be confounded by regional nerve involvement, referred to as radial tunnel syndrome. The deep branch of the radial nerve may be compressed (by pronation and flexion of the wrist) as it passes dorsal to the arcade of Frohse along the fibrous edge of the supinator muscle. Differential signs include increased pain with deep palpation of the radial head and isometrically resisted supination of the forearm, suggesting radial tunnel syndrome, as opposed to tenderness to palpation of the lateral epicondyle and isometrically resisted extension of the wrist, signifying true tennis elbow. The Posterior Interosseous Nerve (PIN) is believed to be crushed under the free edge of the supinator muscle. PIN decompression has been shown to be effective in relieving pain in this region.

Radial tunnel syndrome
(Ref: https://journals.sagepub.com/doi/abs/10.1177/1753193420953990?journalCode=jhsc)

In most cases, the lesion will involve the junctional tissue at the common extensor muscles origin of the lateral epicondyle, specifically the extensor carpi radialis brevis. Most authors agree that involvement of the extensor digitorum communis and extensor carpi ulnaris is rare.

Treatment includes conservative and surgery that conservative is basically the first option. Basic self care such as rest and ice are recommended by me. All treatment, especially physiotherapy will be discussed next time.   

Reference: 

https://www.researchgate.net/publication/335098297_Tennis_elbow_A_clinical_review_article

https://www.jospt.org/doi/pdf/10.2519/jospt.1994.19.6.357

https://www.researchgate.net/publication/230621315_Lateral_epicondylitis_A_review_of_the_literature

https://onlinelibrary.wiley.com/doi/full/10.1111/j.1758-5740.2009.00023.x

https://journal.racketsportscience.org/index.php/ijrss/article/view/65

https://www.hindawi.com/journals/prm/2020/6965381/

https://www.researchgate.net/publication/322102357_Relation_of_Grip_Style_to_the_Onset_of_Elbow_Pain_in_Tennis_Players 

Basic review of Wrist hyperextension pain with tendon instability in Sports

 

Ref: https://fittergolfers.com/

Wrist hyperextension injuries do not develop only ligament or joint instability. It is an occasion to develop pathology on tendon, bone, nerve, and vascular, as well. The biggest cause is overuse induced degenerative that is the result from sports activities and daily activities such as occupational. 

 

Extensor Pollicis Longus (EPL) Tenosynovitis 

            This is one of tendinopathy and tendon instability. It is described as a drummer’s palsy in which stenosing tenosynovitis of the extensor pollicis longus (EPL) is seen in patients subject to long-term repetitive wrist hyperextension. The most common has been seen in gymnasts and platform divers that the pathomechanics are thought to involve impingement of the EPL tendon between the base of the third metacarpal and the Lister tubercle, leading to inflammation, swelling, and a subsequent discrepancy in size between the EPL and its tight, inelastic fibrous compartment. 

Ref: https://vectormine.com/

             Tendon gliding limitation through the third compartment affect a painful snapping sensation and can progress to attenuation and rupture of the tendon. Traumatic injuries in this area can disrupt the tendon’s blood supply or cause compressive swelling (e.g., hematoma formation) within the third extensor compartment which leads to ischemic injury.

Platform diver
(Ref: https://www.pinterest.co.uk/)

            Patients are evaluated with pain and swelling around the Lister tubercle. Palpable clicking or snapping may be felt with EPL firing in cases of stenosing tenosynovitis. Radiographs and MRI can be useful in identifying any bony prominence as a source of attritional tendon injury associated with synovitis or a fracture in the setting of a recent trauma. Sonography is a helpful imaging tool to investigate tendinosis and tenosynovitis, as well.

Sonography or ultrasound image
(Ref: http://highlandultrasound.com/)

            Surgical is generally recommended to treat. While corticosteroid injections may provide a period of pain relief. However, these are typically avoided in athletes because they can lead to tendon attenuation and increased risk for rupture. 

 

Extensor Carpi Radialis Brevis (ECRB) Insertional Tendinitis 

Extensor Carpi Radialis Brevis

(Ref: https://www.orthobullets.com/)

In high - level athletes such as gymnastics, weight lifting, and racquet or stick sports (eg, baseball, tennis, golf) bring repetitive forceful contraction that can cause microtrauma to the tendinous insertion of the ECRB. Long-standing tenosynovitis eventually leads to interstitial tendinosis and tendon attenuation.

Wrist extension during clean & jerk weight lifting
(Ref: https://www.gymreapers.com/blogs/)

It has been seen in individuals, for example, construction workers and secretaries, who perform repeated resisted forearm rotation, wrist extension, and prehension activities.

Activity-related pain over the base of the second and third metacarpals should be done in typical evaluation. In golf, baseball, and lacrosse athletes, the pain is typically in the dominant hand and reproduced at the top of the backswing maximal wrist extension; pain can also occur at the point of impact with the ball (e.g., golf, baseball). On physical examination, there may be point tenderness, swelling, and bogginess over the base of the third metacarpal. Pain with resisted wrist extension and passive wrist flexion is suggestive of ECRB insertional tendinitis. MRI scans will show edematous changes to the distal ECRB and its insertion.

The top of the backswing maximal wrist extension in golfer
(Ref: https://www.bunkered.co.uk/)

Conservative treatment is the first consideration in the early phase primarily via rest/activity avoidance and use of NSAIDs. Corticosteroid injections can be helpful to reduce inflammation and pain but under caution, as they may lead to tendon attenuation and risk for rupture. Goals for nonoperative treatment need physiotherapy to complete symptom relief and full range of motion by 6 weeks, followed by 2 weeks of gradual strengthening and initiation of sport-specific training around week 12, after the patient’s wrist has reached 85% of the strength of the contralateral side.

Lacrosse
(Ref: https://cmsvathletics.com/)

Patients with mild symptoms or faster progression through this general protocol may return to sports sooner. Tenosynovectomy, the surgery, is indicated after 6 to 12 months of failed nonoperative treatment. Postoperative, patients have their wrists immobilized for 2 weeks, followed by a range of motion therapy. At 6 weeks postoperative, the rehabilitation protocol is the same as the nonoperative treatment described above. 

 

Fourth-Compartment Syndrome 

The extensor indicis proprius (EIP) muscle originates along the distal third of the ulna and passes within the fourth compartment, deep and ulnar to the extensor digitorum communis (EDC) tendons. 

Extensor Indicis Proprius 
(Ref: https://proper-cooking.info/)

Increasing of the space occupied within the fourth compartment was known in term “Anomalous” that can cause pathologic increase in compartment pressure with subsequent tenosynovitis, irritation of the posterior interosseous nerve (PIN), pain, and disability. This is pathomechanics to develop forth – compartment syndrome.

Initial treatment is typically nonoperative, with rest, NSAIDs, activity modification, splinting, and corticosteroid injections. Patients who do not respond to prolonged nonoperative treatment should raise suspicion for the presence of aberrant anatomy (e.g., anomalous muscle or tendon). Surgery is indicated for patients without improvement despite 3 to 6 months of nonoperative treatment, which involves decompression via surgical release of the fourth extensor compartment; concomitant tenosynovectomy and reduction or excision of associated anomalous muscles may be performed to decrease the risk of recurrence, particularly in patients who plan to return to sports. 

 

Distal posterior interosseous nerve (PIN) Syndrome 

The PIN is the terminal branch of the radial nerve, which passes through the 2 heads of the supinator and travels to the wrist along the radial floor of the fourth extensor compartment, just under the Lister tubercle. Terminal sensory branches of the PIN cross dorsally over the scapholunate ligament and innervate the dorsal capsule of the wrist.

Posterior Interosseous Nerve (PIN)
(Ref: https://casereports.bmj.com/content/14/10/e245659)

Athletes whose sports require repetitive, forceful hyperextension of the wrist (e.g., gymnasts, football linemen and defensive backs, platform divers, weight lifters), particularly those with hypermobility at baseline, may experience dorsal wrist pain secondary to impingement of the PIN at the wrist. 

On examination will have pain exacerbated by maximal dorsiflexion of the wrist as well as tenderness localized to the fourth extensor compartment along the course of the PIN. 

Gymnasts on balance bar
(Ref: https://blog.orthoindy.com/)

Initial treatment for athletes with suspected distal PIN impingement is nonoperative by immobilization and NSAIDs. Surgical treatment is indicated when PIN neurectomy has been shown to be a safe and effective procedure for providing pain relief in most patients.

 

Avascular Necrosis of the Lunate (Kienböck Disease) 

Sometimes, wrist pain is caused by not enough or a blocked blood supply. Presenting symptoms are often similar to those of wrist sprain without a history of trauma. Dorsal wrist tenderness over the lunate with adjacent reactive synovitis and soft tissue swelling is common. Decreased grip strength and pain with motion are usually present and exacerbated by activity, particularly with extension and axial loading across the wrist (e.g., push-ups or military press). 

Military press or overhead press
(Ref: https://www.inspireusafoundation.org/)

Kienböck disease refers to avascular necrosis of the lunate and is the most common type of idiopathic carpal avascular necrosis. Its origin remains unclear and is likely multifactorial, with local vascular and osseous abnormalities being most commonly implicated. It is most common in men aged 20 to 40 years. 

MRI and the presence of uniform signal change of the lunate compared with the rest of the carpus are used for diagnosis. 

Avascular Necrosis of the Lunate (Kienböck Disease) MRI: Black area at carpal
(Ref: https://www.orthobullets.com/)

Patient symptoms and radiographic staging of disease are the major treatment guidelines. Symptomatic patients in early stages of disease are typically treated initially with cast immobilization, in order to improve lunate vascularity. In later stages, palliative and performed in an attempt to limit continued carpal collapse (e.g., proximal row carpectomy, wrist arthrodesis, denervation).

 

Occult Dorsal Carpal Ganglion 

Occult dorsal ganglion cysts may result from athletic activity and lead to a dorsal impingement syndrome. 60%-70% of these mucin-filled cysts originate from the Scapholunate ligament and most commonly present as a cystic mass extruding between the extensor pollicis longus and extensor digitorum communis tendons. 

Smaller, occult dorsal wrist ganglions are more difficult to identify. An inciting injury to the SL ligament and subsequent degenerative change is thought to lead to formation of occult ganglion cysts, although an inciting injury is only reported in about 10% of patients. 

Dorsal Carpal Ganglion
(Ref: https://quizlet.com/) 

Diagnosis should be considered for all athletes with dorsal wrist pain that becomes worse with dorsiflexion and loading across the wrist joint. They will have maximal tenderness over the SL interval, which is identified by palpating the soft tissues directly over the inline of the Lister tubercle, which may be exacerbated by passive hyperextension of the wrist.

 Initial treatment is nonoperative, with corticosteroid injection directly into the wrist capsule followed by a period of splint immobilization, which can provide pain relief and help with diagnosis. Surgical intervention is effective for patients with significant activity-limiting pain and nonoperative treatment that has failed. 

 

Dorsal Capsular Impingement 

Dorsal wrist impingement (DWI) refers to a disorder characterized by mid dorsal wrist pain attributed to capsulitis or synovitis of redundant capsular tissue impinging between the ECRB tendon and dorsal ridge of the scaphoid. The onset may be relatively minor but leads to swelling and thickening of capsular tissue that is prone to recurrent episodes of impingement and a cycle of aggravation with persistent inflammation. 

Dorsal wrist impingement 
(Ref: https://journals.sagepub.com/doi/full/10.1177/23259671221088610)

In chronic cases, osteophytes may develop along the dorsal scaphoid, lunate, or dorsal rim of the distal radius, which leads to worsening impingement and dorsal impaction. Pain is localized to the ECRB, where it passes over the dorsal scaphoid, which is exacerbated with full wrist extension and loading of the wrist in an extended position (e.g., tabletop push-off test).

Plain-film radiographs are typically normal, and CT scans may show the development of small osteophytes. MRI scans can be helpful in confirming DWI, which may show dorsal capsular thickening and redundancy with signs of inflammation in this area. 

ECRB anatomy
(Ref: https://www.orthobullets.com/)

The most DWI can be cured by conservative within 2 to 3 months by rest, splint immobilization, and NSAIDs. Corticosteroid injections are helpful to break the cycle of capsular inflammation and swelling and often provide significant (70%) pain relief for several weeks. Surgical treatment may be indicated for refractory cases that fail nonoperative management. 

Operative is needed If conservative treatment cannot solve. Postoperatively, patients are placed in a removable wrist orthosis and begin immediate range of motion therapy, with the goal of full wrist motion at 2 to 3 weeks. Strengthening begins after full motion is achieved, and athletes may begin a return-to-sports protocol around 6 weeks postoperatively, when strength is 80% that of the contralateral side. 

These most anatomy and pathologies have talked about Gymnastic, Lister tubercle, second metacarpal and third metacarpal. The treatment consists of conservative such as immobilize with brace and strengthening therapeutic exercise, and surgery that need post operative rehabilitation.

In fact, there are many wrist disorders syndrome in Sports or daily living that we will discuss together later.

 

Reference: 

 https://journals.sagepub.com/doi/pdf/10.1177/23259671221088610 

 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5074830/

 https://www.jospt.org/doi/pdf/10.2519/jospt.2008.2672