Tennis Elbow by Lizl Kotz
Note the neutral wrist on ball contact as Federer hits his backhand.
I’m at net. By way of hand signal, I let me doubles partner know what kind of serve I would like. The serve kicks out wide and high to the backhand. The returner gets his strings on the ball but not early enough to create a good-enough crosscourt angle. I know this is my chance. I’m on the balls of my feet, ready to poach. I squeeze my grip lightly to prepare for the perfect backhand volley. A piercing sharp pain shoots from my elbow down my forearm. I wince as the ball connects with my strings. Worse than the pain, the ball lands at the bottom of the net. I stare at my throbbing elbow. I vaguely remember my elbow aching this morning when I held my coffee cup. How in heaven’s name did it progress from a minor ache to a knife-like pain, sharp enough to bring me to my knees?
Most tennis players battling tennis elbow or lateral epicondylitis has a story similar to this one. A mild tightness is felt in the elbow joint and or the forearm muscles when hitting a backhand groundstroke or volley. This tightness typically quickly progresses to significant discomfort with any gripping or pinching hand movements. A few examples of everyday painful activities are: holding a coffee cup, cutting, writing, turning a knob, pulling a sheet up to make a bed, combing hair and typing. Because the pain is initially mild, many athletes make the mistake of playing through the pain-until one day, they literally can’t hold onto their racket any longer. Once acute inflammation has set in (constant pain), it takes both time and intervention from many angles to return to a pain-free state. Even though lateral epicondylitis is also referred to as tennis elbow, this condition can affect squash players, baseball players, swimmers and non-athletes as well.
Symptoms can last on average from 2 weeks to 2 years. Pain is experienced over the lateral epicondyle (thumb-side) where the forearm extensor muscles originate. The pain can radiate up into the upper arm, down the forearm and sometimes into the third and fourth fingers. The pain quality can be sharp, aching or burning. Pain is exacerbated with hand shaking, grasping and pinching of the fingers and forceful pronation and supination motions such as turning a screwdriver.
The disease process is ignited when the wrist extensor muscles get overused. The extensor muscle belly gets inflamed and painful. This acute pain then moves into the extensor tendon which attaches to the lateral epicondyle. A vicious cycle is set in motion where the tendon fibers degenerate faster than they can regenerate (tenodesis) leaving the tendon weak and vulnerable to further injury. The patient may feel lots of taut bands of muscle or myofascial adhesions along the muscles of the forearm.
* The term “overuse” in sport means repetitive motion but needs to be clarified. Overuse is using a body part repeatedly and more than what it was conditioned for. Thus, overuse will look different for everybody and means that the joint or muscle use exceeded what it was prepared to do.
Risk factors
1) weakness of the forearm extensor muscles not prepared to handle repetitive grasping, gripping and pinching movements ,
2) older age and
3) training errors
Muscle Weakness:
Often times weakness in the shoulder blade/scapular muscles will cause problems down the chain. Our shoulder blade muscles (lower trap, mid-trap, serrates anterior) stabilize our shoulder blade and allow for normal movement activities down the arm. Many athletes have weakness in these core shoulder girdle muscles which then impose unreasonable stabilizing demands of the elbow and wrist muscles. Athletes who get in a habit of performing core stabilizing exercises of the scapular, lower abdominal and hip musculature are able to avoid many nagging inflammatory conditions down the chain. For seasoned tennis players, lateral epicondylitis typically starts with a non-tennis activity such as a big day of gardening or using a screwdriver to put together that large desk that’s been sitting in a box for a year. The extensor muscles are not strong enough to do hours of manual labor (unless they have been slowly conditioned to do so). The tendon gets inflamed and the situation quickly gets exacerbated when this same person then participates in their tennis match with an already inflamed tendon.
Older Age:
The degenerative changes associated with increasing age may be detected as early as the third decade. As we age, our tendons contain less water making them stiffer and more prone to injury. We also know that our collagen regeneration slows after age 30, making our tendons unable to handle repetitive stress as well as they did when we were younger.
Training Errors:
Grip size: Using a racket grip that is too small for your hand will require you to squeeze your grip tighter than what is necessary. If you are experiencing pain in your elbow, hand or forearm, consider increasing your grip size. Use the following finger measuring method to determine if your grip is too small. Hold your racquet like you normally would in your dominant hand, then take the index finger of your non-dominant hand and try to place it in the gap between your fingers and palm; if you can’t place your finger in the gap, your grip is too small. One of the easiest ways to make small increases in grip size is to apply overgrip to your existing grip which comes in different levels of thickness.
String Type: Some strings are stiff and transmit shock to the arm, while others are softer and absorbs some of the shock. Daniel DiNardo from Holy City Tennis in Charleston SC comments on the latest string technology: “Natural gut is still the king when it comes to soft strings. Gut offers the best playability, comfort and ball pocketing or feel. Because gut is expensive, a less expensive option that is also forgiving is synthetic and multifilament string. Multifilaments are made of hundreds of fibers woven together to provide feel and comfort. You can also choose to create a blend of the two strings. The third type of string, polyester, was developed to provide players with a durable string. Players love playing with polyester strings because they feel crisp and helps create spin BUT it is very unforgiving on the arm”. Poly strings should be avoided if a player is prone to inflammatory conditions.
String Tension: String tension is all over the map for most professional players these days. Some players string their rackets as low as 30 pounds while some are at 70 pounds. A lower tension is easier on the arm as the power is created by the racket and the string. A higher tension offers more control but requires power from the arm and not so much from the racket and strings. A player suffering from tennis elbow should consider a string tension in the 40 pound range.
Rackets: Daniel DiNardo from Holy City Tennis in Charleston SC encourages players with any upper extremity pain to consider a newer racket because most racket companies are now using a dampening agent infused into the graphite layup of the racket to help with shock absorption and flexibility of the frame. Some examples would be the Wilson FreeFlex which uses Carbon mapping technology and results in the racket bending at different locations in the frame. Volkl uses and EVA foam sheath layer in the handle of their rackets to help aid in vibration dampening and shock absorption. Babolat uses C2 Pure Feel in their rackets that is a viscoelastic rubber layer throughout the frame which aids in shock absorption.
Technique:
Regardless of the stroke, sound technique starts with early preparation. Early preparation gives the lower body the time to be the power source. Not only do the legs create power with a push force from the ground up, they also create a forward force when the player steps towards the net as the ball is struck. With the body creating this up and forward force, a player won’t be tempted to try and create power by rapidly extending the elbow or wrist or by squeezing the grip too tight.
Treatment
Conservative Treatment:
Tennis elbow can be very painful but typically does resolve without surgery. In my opinion, there is no one treatment that will be “the quick fix”. It typically takes a combination of the interventions listed below and a whole lot of patience:
1. Rest and activity modification.
Do not do any activities that are painful. In this situation, pain is your body’s warning to stop. By continuing to do activities that are painful, you are just prolonging your recovery time. This may mean that you don’t make your bed or start using voice text instead of typing until your elbow is healed up.
2. Ice at least 3 times a day for fifteen minutes at a time. Ice is a natural way to control inflammation and edema.
3. Counterforce bracing.
Elbow braces or compressions sleeves are very helpful in that they help keep pressure off of the inflamed tendon by spreading tension to different parts of your arm. In a way it’s a form of rest for people who truly can’t rest the elbow. I treated a surgeon who does a lot of stitching and had to keep using his arm for work. He did find relief in his elbow by wearing a counterforce brace but eventually the pain moved down to his wrist. Counterforce bracing is a form of rest but not a cure-all.
4. Physical therapy.
Physical therapist are trained at finding ways to modify activities, treat pain and help strengthen the extensor muscles without aggravating the problem. It is crucial to start strengthening the extensor muscles once the acute pain has subsided. Strengthening prevents further injury and facilities healing of the muscle fibers by increasing blood flow and laying down tendon fibers in an organized manner. Eccentric strengthening has been shown to be the most effective at strengthening muscle fibers to its optimum.
5. Massage.
In my experience, much of the pain associated with tennis elbow is due to trigger points that form in the extensor muscle belly and down the tiny forearm muscles. These trigger points cause local pain as well as referred pain down the forearm. Trigger points are taut bands of muscle fibers that are hyper-irritable. Using deep tissue massage daily will help dissolve these trigger points and encourage the re-alignment of these fibers.
6. Injections
Platelet Rich Plasma (PRP) injections have been shown to be more effective than corticosteroid injections. Corticosteroid injections have also come into question when the below study results surfaced this past October:
However, a recent study led by Ali Guermazi, MD, PhD, professor of radiology and medicine at Boston University School of Medicine, found that corticosteroid injections may be associated with complications that potentially accelerate the destruction of the joint and may hasten the need for total hip and knee replacements. “We’ve been telling patients that even if these injections don’t relieve your pain, they’re not going to hurt you,” Dr. Guermazi said. “But now we suspect that this is not necessarily the case.”
Surgical Treatment:
Dr. Peter J. Millett is an internationally recognized orthopedic surgeon who specializes in disorders of the shoulder, knee, elbow and all sports-related injuries. Partner at The Steadman Clinic, Dr. Millett has treated elite athletes from the NFL, NBA, MLB, NHL, PGA, Formula One, X-Games, and the Olympics. “Most cases of tennis elbow, even severe cases, will resolve with conservative, non-surgical treatment. There are three surgical options available if a patient has not responded to prolonged conservative treatment:
Opening the tendon, removing the damaged portion and then repairing the tendon.
Doing the same procedure using an arthroscopic approach to remove the damaged part of the tendon
Using ultrasound guidance and a percutaneous approach to remove the damaged tendon (also called TENEX procedure). All three surgical methods have been effective.”
The bottom line is, don’t do what most athletes love to do: ignore the pain. Sticking your head in the sand will not be helpful this time. Lateral epicondylitis is painful and can be very debilitating for athletes, musicians or anyone who needs to use their hand. I think this includes just about everybody. Respect the pain, treat early and be patient while you heal.