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definitions - Tennis_elbow

tennis elbow (n.)

1.painful inflammation of the tendon at the outer border of the elbow resulting from overuse of lower arm muscles (as in twisting of the hand)

Tennis Elbow (n.)

1.(MeSH)A condition characterized by pain in or near the lateral humeral epicondyle or in the forearm extensor muscle mass as a result of unusual strain. It occurs in tennis players as well as housewives, artisans, and violinists.

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Tennis elbow

Classification and external resources

Left elbow-joint, showing posterior and radial collateral ligaments. (Lateral epicondyle visible at center.)
ICD-10 M77.1
ICD-9 726.32
DiseasesDB 12950
eMedicine orthoped/510 pmr/64 sports/59
MeSH D013716
  Example of repetitive movement which may cause tennis elbow
  Activity which may cause pain (Lifting with the palm down)

Lateral epicondylitis or lateral epicondylalgia, known colloquially as tennis elbow, shooter's elbow, and archer's elbow or simply lateral elbow pain, is a condition where the outer part of the elbow becomes sore and tender. Since the pathogenesis of this condition is still unknown, there is no single agreed name. While the common name "tennis elbow" suggests a strong link to racquet sports, this condition can also be caused by sports such as swimming and climbing, the work of manual workers and waiters, as well as activities of daily living.[1][2]

Tennis elbow is an overuse injury occurring in the lateral side of the elbow region, but more specifically it occurs at the common extensor tendon that originates from the lateral epicondyle. The acute pain that a person might feel occurs as one fully extends the arm.

In one study,[3] data was collected from 113 patients who had tennis elbow, and the main factor common to them all was overexertion. Sportspersons as well as those who used the same repetitive motion for many years, especially in their profession, suffered from tennis elbow. It was also common in individuals who performed motions they were unaccustomed to. The data also mentioned that the majority of patients suffered tennis elbow in their right arms.

Runge is usually credited for the first description in 1873 of the condition.[4] The term tennis elbow was first used in 1883 by Major in his paper "Lawn-tennis elbow".[5][6]


  Signs and symptoms

  • Pain on the outer part of elbow (lateral epicondyle).
  • Point tenderness over the lateral epicondyle – a prominent part of the bone on the outside of the elbow.
  • Gripping and movements of the wrist hurt, especially wrist extension[citation needed] and lifting movements.
  • Activities that use the muscles that extend[citation needed] the wrist (e.g. pouring a pitcher or gallon of milk, lifting with the palm down) are characteristically painful.
  • Morning stiffness.

The symptoms associated with tennis elbow are, but are not limited to: radiating pain from the outside of your elbow to your forearm and wrist, pain during extension of wrist[citation needed], weakness of the forearm, a painful grip while shaking hands or torquing a doorknob, and not being able to hold relatively heavy items in the hand. The pain is similar to the pain of the condition known as Golfer's elbow but the latter occurs at the medial side of the elbow.[1]


During early experiments, it was thought that tennis elbow was primarily caused by overexertion. Studies have shown that trauma such as direct blows to the epicondyle, a sudden forceful pull, or forceful extension have caused more than half of these injuries.[3]

One explanation of how tennis elbow may come about is proposed by Cyriax. The theory states that there are microscopic and macroscopic tears between the common extensor tendon and the periosteum of the lateral humeral epicondyle. An operation conducted in this study showed that 28 out of 39 patients showed tearing at the tendon cuff. Kaplan stated that the radial nerve was significantly involved in tennis elbow. He noted the constriction of the radial nerve by adhesions to the capsule of the radiohumeral joint and the short extensor muscle of the wrist. Evidence found that many differed in how they contracted tennis elbow. Disorders such as calcification of the rotator cuff, bicipital tendinitis, or carpal tunnel syndrome may increase chances of tennis elbow.[3]


The pathophysiology of lateral epicondylitis is degenerative. Non-inflammatory, chronic degenerative changes of the origin of the extensor carpi radialis brevis (ECRB) muscle are identified in surgical pathology specimens.[7] It is unclear if the pathology is affected by prior injection of corticosteroid.

Among tennis players, tennis elbow is believed to be caused by the repetitive nature of hitting thousands and thousands of tennis balls which lead to tiny tears in the forearm tendon attachment at the elbow.[8]

The extensor digiti minimi also has a small origin site medial to the elbow which can be affected by this condition. The muscle involves the extension of the little finger and some extension of the wrist allowing for adaption to "snap" or flick the wrist – usually associated with a racquet swing. Most often, the extensor muscles become painful due to tendon breakdown from over-extension. Improper form or movement allows for power in a swing to rotate through and around the wrist – creating a moment on that joint instead of the elbow joint or rotator cuff. This moment causes pressure to build impact forces to act on the tendon causing irritation and inflammation.

The following speculative rationale is offered by proponents[who?] of an overuse theory of etiology: The extensor carpi radialis brevis has a small origin and does transmit large forces through its tendon during repetitive grasping. It has also been implicated as being vulnerable during shear stress during all movements of the forearm.

While it is commonly stated that lateral epicondylitis is caused by repetitive microtrauma/overuse, this is a speculative etiological theory with limited scientific support that is likely overstated.[7] Other speculative risk factors for lateral epicondylitis include taking up tennis later in life, unaccustomed strenuous activity, decreased mental chronometry and speed and repetitive eccentric contraction of muscle (controlled lengthening of a muscle group).


Another factor of tennis elbow injury is experience and ability. The proportion of players who reported a history of tennis elbow had an increased number of playing years. As for ability, poor technique increases the chance for injury much like any sport. Therefore an individual must learn proper technique for all aspects of their sport. The competitive level of the athlete also affects the incidence of tennis elbow. Class A and B players had a significantly higher rate of tennis elbow occurrence compared to class C and novice players. However, an opposite, but not statistically significant, trend is observed for the recurrence of previous cases, with an increasingly higher rate as ability level decreases.[1]

Other ways to prevent tennis elbow:

  • Decrease the amount of playing time if already injured or feel pain in outside part of elbow
  • Stay in overall good physical shape
  • Strengthen the muscles of the forearm (Pronator quadratus, Pronator teres and Supinator muscle), the upper arm (biceps, triceps, Deltoid muscle), the shoulder and upper back (trapezius)
  • Increased muscular strength will increase the stability of joints such as the elbow
  • Like other sports, use equipment appropriate towards your ability, body size and muscular strength.[1]


To diagnose tennis elbow, the physician performs a battery of tests in which pressure is placed on the affected area while the patient is asked to move the elbow, wrist, and fingers. X-rays are used to confirm and distinguish possibilities of existing causes of pain that are not related to Tennis Elbow, such as fracture or arthritis. Medical ultrasonography and magnetic resonance imaging (MRI) are other valuable tools for diagnosis but are frequently avoided due to the high cost.[1] MRI screening can confirm excess fluid and swelling in the affected region in the elbow, such as the connecting point between the forearm bone and the extensor carpi radialis brevis.

The diagnosis is made by clinical signs and symptoms, which are both discrete and characteristic. With the elbow fully extended, there are points of tenderness over the affected point on the elbow, which is the origin of the extensor carpi radialis brevis muscle from the lateral epicondyle (extensor carpi radialis brevis origin). There will also be pain with passive wrist flexion and resistive wrist extension (Cozen's test).[9]

Depending upon the severity and quantity of multiple tendon injuries that are built up, the extensor carpi radialis brevis may not be fully healed by conservative treatment. Nirschl has defined four stages of lateral epicondylitis, showing the introduction of permanent damage beginning at Stage 2.

  1. Inflammatory changes that are reversible
  2. Nonreversible pathologic changes to origin of the extensor carpi radialis brevis muscle
  3. Rupture of ECRB muscle origin
  4. Secondary changes such as fibrosis or calcification.[10]


Evidence for the treatment of lateral epicondylitis is poor.[11] There are clinical trials addressing many proposed treatments, but the quality of the trials is poor.[12] In some cases, severity of tennis elbow symptoms mend without any treatment within six to twenty-four months. However, if tennis elbow is left untreated, it can lead to chronic pain that degrades quality of daily living.[1]


There are several recommendations regarding prevention, treatment, and avoidance of recurrence that are largely speculative[7] including stretches and progressive strengthening exercises to prevent re-irritation of the tendon[13] [14] and other exercise measures.

Evidence suggests that joint mobilization with movement directed at the elbow resulted in reduction in pain and improved function.[15] Positive results have been found with manipulative therapy directed at the cervical spine, although data regarding long-term effects were limited.[16] Low level laser therapy administered at specific doses and wavelengths directly to the lateral elbow tendon insertions offers short-term pain relief and less disability in LET, both alone and in conjunction with an exercise regimen.[17]


Topical non-steroidal anti-inflammatory drugs (NSAIDs) to relieve lateral elbow pain in the short term, however there were no improvements found in functional outcomes. Injected NSAIDs were suggested to be better than oral NSAIDs. There was insufficient evidence to recommend or discourage the use of oral NSAIDs.[18]

Corticosteroid injection are effective in the short term[19] however are of little benefit after a year compared to a wait and see approach.[20] Complications from repeated steroid injections include skin problems such as hypopigmentation and fat atrophy leading to indentation of the skin around the injection site.[19]

Botulinum toxin type A to paralyze the common extensor origin chronic tennis elbow that has not improved with conservative measures.[21]


In recalcitrant cases, surgery may be an option.[22]


Response to initial therapy is common, but so is relapse (18% to 50%) and/or prolonged, moderate discomfort (40%).


In tennis players, about 39.7% have reported current or previous problems with their elbow. Less than one quarter (24%) of these athletes under the age of 50 reported that the tennis elbow symptoms were "severe" and "disabling." While 42% over 50 identified severe and disabling symptoms. More women (36%) than men (24%) considered their symptoms to be severe and disabling. Tennis elbow is more prevalent in individuals over 40, where there is about a 4-fold increase among men and 2-fold increase among women. Tennis elbow equally affects both sexes and although men have a marginally higher overall prevalence rate as compared women, this is not consistent within each age group, nor is it a statistically significant difference.[23]

Playing time is one factor in tennis elbow occurrences. However, an increased incidence with increased playing time is statistically significant for only respondents under the age of 40. Individuals over the age of 40 who played over 2 hours, had a 2-fold increase in chance of injury. Those under 40 had a 3.5 times increase compared to those who played less than 2 hours per day.[1]

  See also


  1. ^ a b c d e f g "Tennis Elbow - MayoClinic.com." Mayo Clinic Medical Information and Tools for Healthy Living - MayoClinic.com. 15 Oct. 2008. Web. 10 Oct. 2010. [1]
  2. ^ Tennis elbow: even cricketers and housewives can get it, a Times of India article dated September 4, 2004
  3. ^ a b c KURPPA, K., WARIS, P. and ROKKANEN, P. Tennis elbow: Lateral elbow pain syndrome. Scand j. work environ. & health 5 (1979): suppl. 3, 15-18. A review of the etiology, occurrence and pathogenesis of "tennis elbow" is presented.
  4. ^ Runge F. Zur Genese und Behandlung des Schreibekrampfes. Berliner Klin Wochenschr. 1873;10:245–248.
  5. ^ Major HP. "Lawn-tennis elbow". BMJ. 1883;2:557.
  6. ^ Kaminsky SB, Baker CL; Baker (December 2003). "Lateral epicondylitis of the elbow". Techniques in Hand & Upper Limb Surgery 7 (4): 179–89. DOI:10.1097/00130911-200312000-00009. PMID 16518219. 
  7. ^ a b c Boyer MI, Hastings H (1999). "Lateral tennis elbow: "Is there any science out there?"". Journal of Shoulder and Elbow Surgery 8 (5): 481–91. DOI:10.1016/S1058-2746(99)90081-2. PMID 10543604. 
  8. ^ What is tennis elbow? from the BBC Sport Academy website
  9. ^ Tennis elbow from the MedlinePlus Medical Encyclopedia
  10. ^ Owens, Brett D; Moriatis Wolf, Jennifer; Murphy, Kevin P (2009-11-03). "Lateral Epicondylitis: Workup". eMedicine Orthopedic Surgery. http://emedicine.medscape.com/article/1231903-diagnosis. Retrieved 2010-04-19. 
  11. ^ Bisset L, Paungmali A, Vicenzino B, Beller E (July 2005). "A systematic review and meta-analysis of clinical trials on physical interventions for lateral epicondylalgia". British Journal of Sports Medicine 39 (7): 411–22; discussion 411–22. DOI:10.1136/bjsm.2004.016170. PMC 1725258. PMID 15976161. //www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pmcentrez&artid=1725258. 
  12. ^ Cowan J, Lozano-Calderón S, Ring D (August 2007). "Quality of prospective controlled randomized trials. Analysis of trials of treatment for lateral epicondylitis as an example". The Journal of Bone and Joint Surgery 89 (8): 1693–9. DOI:10.2106/JBJS.F.00858. PMID 17671006. 
  13. ^ Stasinopoulos D, Stasinopoulou K, Johnson MI (December 2005). "An exercise programme for the management of lateral elbow tendinopathy". British Journal of Sports Medicine 39 (12): 944–7. DOI:10.1136/bjsm.2005.019836. PMC 1725102. PMID 16306504. //www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pmcentrez&artid=1725102. 
  14. ^ Tennis elbow
  15. ^ Vicenzino B, Cleland JA, Bisset L. (2007). "Joint Manipulation in the Management of Lateral Epicondylalgia: A Clinical Commentary". Journal of Manual & Manipulative Therapy 15 (1): 50–56. DOI:10.1179/106698107791090132. PMC 2565595. PMID 19066643. //www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pmcentrez&artid=2565595. 
  16. ^ Herd CR, Meserve BB. (2008). "A Systematic Review of the Effectiveness of Manipulative Therapy in Treating Lateral Epicondylalgia". Journal of Manual & Manipulative Therapy 16 (4): 225–37. DOI:10.1179/106698108790818288. PMC 2716156. PMID 19771195. //www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pmcentrez&artid=2716156. 
  17. ^ Bjordal JM, Lopes-Martins RA, Joensen J, Couppe C, Ljunggren AE, Stergioulas A, Johnson MI (2008). "A systematic review with procedural assessments and meta-analysis of Low Level Laser Therapy in lateral elbow tendinopathy (tennis elbow)". BMC Musculoskeletal Disorders 9: 75. DOI:10.1186/1471-2474-9-75. PMC 2442599. PMID 18510742. //www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pmcentrez&artid=2442599. 
  18. ^ Green S, Buchbinder R, Barnsley L, Hall S, White M, Smidt N, Assendelft W (2002). Green, Sally. ed. "Non-steroidal anti-inflammatory drugs (NSAIDs) for treating lateral elbow pain in adults". Cochrane Database of Systematic Reviews 2 (2): CD003686. DOI:10.1002/14651858.CD003686. PMID 12076503. http://www.ncbi.nlm.nih.gov/pubmed/12076503. 
  19. ^ a b Coombes, BK; Bisset, L, Vicenzino, B (2010 Nov 20). "Efficacy and safety of corticosteroid injections and other injections for management of tendinopathy: a systematic review of randomised controlled trials". Lancet 376 (9754): 1751–67. DOI:10.1016/S0140-6736(10)61160-9. PMID 20970844. 
  20. ^ Haines T, Stringer B (April 2007). "Corticosteroid injections or physiotherapy were not more effective than wait and see for tennis elbow at 1 year". Evidence-based Medicine 12 (2): 39. DOI:10.1136/ebm.12.2.39. PMID 17400631. 
  21. ^ Kalichman, L; Bannuru, RR, Severin, M, Harvey, W (2011 Jun). "Injection of botulinum toxin for treatment of chronic lateral epicondylitis: systematic review and meta-analysis". Seminars in arthritis and rheumatism 40 (6): 532–8. DOI:10.1016/j.semarthrit.2010.07.002. PMID 20822798. 
  22. ^ Lo, MY; Safran, MR (2007 Oct). "Surgical treatment of lateral epicondylitis: a systematic review". Clinical orthopaedics and related research 463: 98–106. DOI:10.1097/BLO.0b013e3181483dc4. PMID 17632419. 
  23. ^ Gruchow, William, and Douglas Pelletier. "An epidemiologic study of tennis elbow: Incidence, recurrence, and effectiveness of prevention strategies." American Journal of Sports Medicine. 7.4 (1979): 234-238. Print.

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