Yim Physio Near Me: 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.