AKA Extensor Tendinopathy/ Lateral Epicondylosis
The primary pathological process is thought to be degeneration of the extensor carpi radialis brevis tendon, usually within 1-2cm of its attachment. There is an invasion of fibroblasts and vascular granulation tissue rich in nociceptive nerve endings. There is often continued or repetitive use of wrist extension. The grip on the racquet may be too small or poor technique is present. ECRB crosses 2 joints and works eccentrically at both ends during certain manoeuvres, and may be compressed by the radial head.
There are 2 distinct presentations: The most common is insidious onset of pain 24-72 hours after performing an unaccustomed activity involving wrist extension. The other presentation is a sudden onset of lateral elbow pain associated with a single instance of exertion involving the wrist extensors.
Examination shows maximal area of tenderness 1-2cm distal to the lateral epicondyle. The pain is typically reproduced with resisted wrist extension (particularly when the wrist is pronated and radially deviated (Mills’ test) and with resisted extension of the middle finger. There may be neural tension on the upper limb tension test and there may be decreased ROM in the neck particularly around the C5/6 apophyseal joint.
Predisposing factors should be treated (e.g. bad technique, wrong grip size) and biomechanical deficits corrected (assess the wrist, shoulder, scapula, neck and back).
Common faults in tennis include:
- “leading elbow”
- early wrist flexion with abrupt extension on impact
- exaggerated wrist pronation
- ball impact in the lower portion of the racquet.
Racquet size and stiffness have been postulated as causative factors, although neither has been definitively shown. A stiffer racquet transmits more vibration to the arm. Higher string tension will transmit more force through to the arm. Vibration-damping devices placed between the strings have been shown to decrease string vibration but with no benefit to the arm. A larger grip size has been shown to produce lower muscle activity in the forearm extensors.
Control pain with rest, ice and NSAIDs. Modalities, stretching and massage may be used. Dry needling may help with trigger points.
Counterforce bracing can be used during the rehab.
Corticosteroid injection and iontophoresis may be used (although benefits are controversial), other adjunctive treatment may be considered (PRP, GTN patches, shockwave and/or sclerosant injection) with surgery as a last resort.
To improve wrist flexion mobility place the wrist extensors on passive stretch with the elbows extended. As flexibility starts to approach normal, strengthening should commence with isometric contraction and progress to concentric and then eccentric exercises. A progressive resistance programme is incorporated which may include free weights or a Theraband. Use a weighted rod to strengthen the muscles of pronation and supination. This should follow with a graduated return to activity.