Tennis Elbow: How To Avoid It

With fantasies of spring upon us, it is an ideal time to begin a program to prevent tennis or golf elbow from putting a damper on your return to the courts and courses. These two overuse injuries re-emerge annually as the spoilers of the prime-time seasons for recreational sports. Both are preventable.

What is Tennis Elbow?
Like other overuse injuries, both tennis and golf elbow are a result of placing excessive demand on muscles and tendons that are not equipped to handle the stress.

Lateral Epicondylitis is the technical name for tennis elbow. The literal definition is that there is an inflammation ("itis") at the tendons attaching to the bony prominence at the outer (lateral) region of the elbow (the epicondyle). The lateral epicondyle is on the thumb side of the elbow when the palm is facing upward. The tendons that attach to it are those connecting the muscles that extend the wrist and fingers. Symptoms can range from mild and transient to those that prevent even lifting a plate or cup of coffee. In actuality, rather than a simple inflammation, epicondylitis is generally a result of a degenerated tendon (tendinosis) or one that is torn. One tendon in particular is usually the culprit, and that is the extensor carpi radialis brevis tendon (known as the ECRB).

What Contributes to Tennis Elbow?
First off, you don't have to play tennis to join the club. Any repetitive stress that entails use of the wrist and finger extensors can lead to their overuse and subsequent breakdown. If the tissues are not sufficiently strong or flexible it takes less demand to overdo it. If you begin a new activity or resume playing a sport after a layoff due to injury or seasonal abstinence, it is important to establish a foundation of strength and flexibility that will prepare you to compete safely. In addition, it is best to ease into the season by ramping up your playing time gradually.

There are other factors besides strength and flexibility that can come into play for tennis buffs looking to prevent lateral epicondylitis. First, consult a pro to help you choose your racquet. Many pros recommend that you spend the extra money to string your racquet with gut, which is softer and more forgiving than some of the synthetics. Just as with the wrong strings, a racquet that is too long, too rigid or too light, or one that has the wrong grip size (generally too small) or is strung too tightly will increase the vibrations that travel up through the hand and arm putting a player at greater risk of injury.

Poor stroke mechanics are another big reason that recreational tennis players suffer from tennis elbow. This is particularly true for those who have a wristy backhand or who maintain a rigid forearm and don't follow-through properly on their backhands. Hitting the ball in the sweet spot of the racquet is also a key to minimizing the vibrations that otherwise place excessive stress on the muscles and tendons. Taking some lessons to perfect your form can go a long way toward helping to prevent unnecessary demands on your body.

Do Tennis Pros Get Tennis Elbow?
The answer to this question isn't as simple as you might think. Though there have certainly been instances of high-level competitors suffering from lateral epicondylits, it isn't common amongst tennis pros. In spite of the concentration of time they spend on the court, with their excellent conditioning, ongoing coaching and optimal equipment, tennis elbow is not nearly as prevalent in the pro ranks as in the recreational population.

The big however, is that pro tennis players are more likely to suffer from Golf Elbow than Tennis Elbow. This is largely due to the extraordinary spin that many put on the ball when serving, or even in their groundstrokes. This places undue stress on the opposite side of the forearm.

What is Golf Elbow?
Basically, Golf Elbow is the opposite of Tennis Elbow -- it is generally a tendinosis of the wrist flexor or pronator teres tendons (the latter is the extension of a muscle that twists the palm downward). These tendons attach to the inner (medial) epicondyle at the elbow (on the pinky side of the elbow with the palm facing upward). Thus it is also referred to as medial epicondylitis. Occasionally, Golf Elbow also entails compression and tenderness at the ulnar nerve, the area that hurts when you hit your "funny bone."

Like Tennis Elbow for recreational tennis players, weekend hackers may wind up with Golf Elbow because of a lack of conditioning, excessive play, unforgiving or poorly fitted equipment as well as poor form. An incorrect grip or swing is often at fault.

As for Tennis Elbow, you don't have to play the game to suffer the injury. Repetitive activities placing demand on the flexors include: home improvement projects that involve hammering or painting, keyboarding for the office worker or even the throwing motion in overhead sports. The latter is again why elite tennis players may suffer this ailment -- the serve and overhead strokes being the primary culprits. If you are learning a spin serve, watch the practice time and mix it up a bit.

Anti-inflammatory medication, ice and cross friction massage are generally used to treat the inflammation, and stretching the involved muscles and tendons is also very important. It is crucial to strengthen the forearm, wrist and hand muscles as well, but only in a progressive manner that does not provoke any discomfort or pain. Begin with submaximal isometrics (exerting a gently resisted force without movement) and eccentric exercises (providing resistance to the lengthening of a muscle from its shortened position), before moving on to resisted isotonic exercise. The latter combines both concentric (shortening) and eccentric (lengthening) contractions by moving through an arc of motion using weights or resistive exercise bands.

For Tennis Elbow, the focus is on strengthening the wrist extensors and forearm supinators (which turn the palm upward), and when treating Golf Elbow, the focus is on the wrist flexors and forearm pronators (which turn the palm downward).

It is also generally helpful to wear a brace designed to lessen the stress to the involved tissues with routine activity. Some advocate forearm straps while other suggest wearing a wrist splint to actually prevent the offending motion. I have found both to be effective and may opt for the restrictive splint in the acute phase, while preferring the Aircast Armband thereafter, to allow for greater function and return to play. Of course, it is important to minimize the ongoing stress to the area by limiting or refraining from problematic activities while rehabilitating. Rest and anti-inflammatory medications alone are never the answer though, as inactivity will result in further deconditioning of the muscles, often leading to recurrent injury once activity is resumed.

When performing activities of daily living, those with Tennis Elbow should try to grip things with the palm up (forearm supinated) while the opposite is true for those with Golf Elbow.

A Lidocaine injection may be used to differentially diagnose Tennis or Golf Elbow by providing temporary symptom relief. Some physicians jump right to Cortisone injections for treatment. I feel strongly that Cortisone should not be a first resort. Though injections do address the inflammation, they do not impact the causes of a condition. Without restoring normal joint range of motion, muscle flexibility and strength to the forearm, wrist and hand, the condition is likely to return. Cortisone combined with other restorative treatments is more beneficial, though it is best to first approach care more conservatively to see if injection can be avoided.

A variety of newer treatments are also in use now, and their effectiveness is yet to be fully evaluated. These include PRP (platelet rich plasma therapy), Prolotherapy and Shock Wave Therapy.

Surgery to repair the defect in the tendon is a last resort and is generally only used in more extreme or chronic instances, when conservative management has failed. However, surgically lengthening the expansion of the involved tendons is generally discouraged because of the resultant weakening of the tissue.

So, start your program now to keep injuries away. Get fit to play, rather than simply playing to get fit!