You just upped the load of your weight training or might have recently engaged in an activity which was strenuous and involve repetitive movements of the wrist and elbow. This later results in a burning sensation on the outer aspect of the elbow which is painful, sore and very sensitive to the touch. All this describes a condition called ‘Tennis elbow’ which is more commonly known as lateral epicondylitis among clinicians.
Tennis elbow was thought to be common only among tennis players. However, this condition has been affecting more than just sports people as it is actually common in occupations which involve repetitive forearm rotational activities.
It has been estimated that only 5-10% of cases occur in tennis players. More often than not, recreational players are more susceptible than elite tennis athletes due to improper stroke technique or faulty equipment use.
Pain in the elbow was first described as ‘writer’s cramp’ by Runge in 1873 and later was called ‘Lawn Tennis Arm’ now known as Tennis elbow or lateral epicondylitis. Nirschl and Pettrone in 1979, described the pathoanatomy of the area as tendinosis.
Though the acute stages of tendon injury can have an inflammatory component, chronic tennis elbow is considered as a degenerative pathology rather than a tendonitis. Degenerative in this sense as it is more a failed reparative process of the tendon with associated cellular changes rather than active inflammation causing the pain. Therefore, terms like “tendinopathy” and “epicondylalgia” are more often being used by professionals to describe this painful condition which affects both office workers and sports people alike.
All about Lateral Tendinopathy (‘Pathy’ meaning non-inflammatory disorder) or Lateral Epicondylalgia (‘algia‘ meaning pain)
- What is the lateral epicondyle of the Elbow?
The elbow joint consists of three long bones which meet in the middle portion of the arm. The upper arm bone (humerus) meets the two inner bone of the forearm (ulna) and the outer bone of the forearm (radius) to form a hinge joint. The radius and ulna bones are responsible for rotational movements of your forearm.
The elbow functions to move the arm like a hinge (forward and backward) and in rotation (twisting outward and inward). The outer bone of the elbow is referred to as the lateral epicondyle and is a part of the humerus bone.
- What are the tendons that attach to the lateral epicondyle?
A tendon is a part of the muscle. Tendon function by joining the muscle to the bone providing leverage to perform a movement.
At the lateral epicondyle, the tendons of the extensor muscles start and runs along the forearm. Extensor muscles again end into tendons that pass over the wrist and attach to your fingers. These tendons cause upward or outward movement of the wrist and fingers.
Extensor Carpi Radialis Brevis (ECRB) – Commonly affected muscle
When performing movements at the wrist or by holding the wrist downwards with the forearm in pronation (Palm facing downwards). The extensor muscles especially extensor carpi radialis brevis is at its maximum length.
As the origin of ECRB muscle lies proximal to the axis of rotation for bending and straightening the elbow, it is subjected to shearing stress and most commonly affected in movements of the forearm and wrist.
What are the causes of lateral tendinopathy or epicondylalgia?
- Overuse injury
The repetitive motion of the wrist or any activity that requires excessive constant gripping/squeezing can cause injury to the extensor tendons.
Individuals who perform multiple sets of dips, push ups and chin ups can also develop pain and injury. Repetitive exercises that involve excessive wrist extension and forearm rotation stresses the extensor tendon. Especially beginners who are trying to perform exercises which their bodies are not used to. They may be executing these exercises with improper posture, incorrect body alignment or bad technique, which predisposes them to painful symptoms of lateral tendinopathy.
- Weak Scapula Muscles
In a research study published in Journal of Orthopaedic & Sports Physical Therapy (2015), impairments of scapular musculature strength and endurance in individuals with tennis elbow was found. This suggested that muscles of the shoulder and scapula play a role in movements in the forearm and improving the strength and endurance of these muscles will prove beneficial.
- Faulty techniques
During Racket sports, the overload occurs at the extensor tendons especially in the backhand stroke that is hit with improper technique. The key is to use the body weight and strength from the shoulder than overloading the forearm extensor muscles alone. In a faulty stroke, the elbow is straightening doing the racket motion.
In the game of tennis, the following maneuvers can lead to tennis elbow:
1. One-handed backhand with poor form and increased load on extensor tendons.
2. A late forehand swing resulting in bending the wrist significantly stressing the extensor origin.
3. Snapping and turning the wrist while serving with full power
- Faulty Equipments
A rigid and small size racket causes more compressive forces on the extensor muscles. Even though a stiff racket gives the player more power and control, a lot of compressive forces affect the forearm. The grip of the racket if too small or too large may require more strength to hold the racket. In both cases, the player may have to grip the racket too tightly to prevent it from twisting, and high grip force may increase the risk of injury.
High thicker string tension is problematic for the forearm because it reduces the dwell time of the ball on the strings. The lesser contact time of the tennis ball means that the shock of the ball impacts more to the forearm muscles.
Old, wet and soft tennis balls affect the impact and contact point on the racquet requiring more effort from the forearm muscles during impact.
What happens if you have an injury?
Tendinopathy is the result of overuse activity of the extensor muscles causing the tendons at the lateral epicondyle to have micro tears and reduce its blood supply. The tendon tissue develops large nociceptors that cause severe pain. Pain substances (substance-P and CGRP) irritates the surrounding nerve fibers to possibly inflame which further adds to the chronic nature of the painful condition. With the amount of pain, stiffness sets in causing weakness in the extensor muscles of the forearm affecting grip strength and daily activities. Chronic degenerative changes are seen in the collagen tissue of the extensor tendons that further worsens the condition.
Considering its severity from mildly irritating to a debilitating chronic painful condition, it can have a significant impact on social and occupational life.
How can you prevent tennis elbow?
If your injury is caused by an activity that involves placing repeated strain on your elbow joint, such as tennis or repetitive push-up workouts, changing your technique may alleviate the problem. Identifying and learning correct techniques, postural awareness and feedback for an experienced coach would be beneficial.
The best advice is to avoid too much stress on the muscles and tendons surrounding your elbow engaging in overuse activities. Mostly the condition is reversible with rest and treatment which will help prevent the condition getting worse.
Having said that, if it’s just an irritation, there are some precautions you would need to consider immediately while playing tennis. Watch out for faulty strokes or a playing situation which seems to exacerbate the problem. Get more information on the racket dynamics, tennis ball type and strings so that you can avoid injuries due to faulty equipment use.
Due to the insidious nature of the condition and a wait-and-see approach by many individuals, this condition becomes more chronic and debilitating. If pain persists and restricts the movements of the elbow, it will be best for you to get your elbow examined by experts to prevent any further damage.