Tennis Elbow and the Tennis Racket

What is Lateral Epicondylitis?

As the second most commonly diagnosed orthopedic condition in the upper limb, lateral epicondylitis or “tennis elbow” does not exclusively affect tennis players. However, it is common elbow complaint got that nick name for a reason. Lateral epicondylitis primarily results from degeneration of fibers of the extensor carpi radialis brevis (ECRB) or less commonly the extensor digitorum communis (EDC). The term “epicondylitis” is actually a misnomer. The pathology results from a process of wear and tear and overuse rather than acute inflammation The primary culprit is felt to be overuse of the wrist extensors.

Could my ground strokes be the problem?

The backhand, with its utilization of wrist extensors, has frequently been implicated as a culprit in the development of lateral epicondylitis. One handed backhands that lack the stabilization of the nondominant hand or novice players who lack wrist stability in their stroke or hyperextend their wrist are particularly at risk.

What about my racket?

In addition to utilizing tennis professionals to improve stroke mechanics, what other factors need to be considered with the tennis player with lateral epicondylitis? Picking the proper racket is a first step. The switch to rackets composed of graphite allowed for a lighter, stiffer racket that could be swung faster and produce more power. However, increased stiffness means the racket vibrates faster which has been proposed to be an etiologic factor with tennis elbow. Switching to a less stiff racket or one with a larger head size may reduce vibration and help the affected player. Similarly, improper grip size may make a player grip the racket handle too tightly imparting increased strain on wrist extensors.  Kinematic studies of elite players tend to decrease their grip during the follow-through phase of their stroke which reduces the force transmitted to the elbow.

Should I change my strings?

String tension and the type of string a player uses may also need to be adjusted in players with tennis elbow. Reducing string tension or switching to a more forgiving string (such as natural gut) may limit force transmission to the wrist extensors and elbow. Interestingly, despite their popularity, string dampeners have not been shown to lower vibratory force on the elbow.

What other treatments should be considered?

Even without treatment, the symptoms of lateral epicondylitis frequently resolve within 6 to 12 months so conservative management should be the first approach. Athletes usually don’t want to take that much time off their sport so physiotherapy consisting of stretching and strengthening the extensor musculature of the forearm. Splinting and oral nonsteroidal anti-inflammatory medication can provide short term relief. Corticosteroid injections have been a common treatment for lateral epicondylitis although results one year later do not show any improvement over more conservative measures. Microtenotomy where a needle is inserted in the affected area to stimulate bleeding (and thus healing) and infiltration of autologous blood platelet-rich plasma (PRP) have shown promising results. Finally, surgical management with ECRB release is an option for truly recalcitrant cases.

References:

 Chung KC and Lark ME. Upper Extremity Injuries in Tennis Players: Diagnosis, Treatment and Management. Hand Clin 2017;33(1):175-186

De Smedt T, De Jong A, Van Leemput W, Lieven D and Van Glabbeek F. Lateral epicondylitis in tennis: update on aetiology, biomechanics and treatment. BJSM 2007;41 (11) 816-819.

Elliot B. Biomechanics and Tennis. BJSM; 2006; 40; 392-396.

Hennig EM. Influence of Racket Properties on Injuries and Performance in Tennis. Exerc. Sport Scie. Rev 2007.35(2)62-66.

Rossi J, Vigouroux l, Barla C and Berton E. Potential Effects of Racket Grip Size on Lateral Epicondilalgy Risks. Scand J Med Sci Sports 2014;24:e462-e470.

Mohandhas BR, Makaram N, drew TS, Wang W, Arnold GP and Abboud RJ. Racquet String Tension Directly Affects Force Experienced at the Elbow: Implications for the Development of Lateral Epicondylitis in Tennis Players. Shoulder & Elbow; 2016; 8(3):184-191.

Miller S. Modern Tennis Rackets, Balls and Surfaces. BJSM. 2006. 40;401-405.

Hatch GF, Pink MM, Mohr KJ, Sethi PM and Jobe FW. The Effect of Tennis Racket Grip Size on Forearm Muscle Firing Patterns. AJSM. 2006; 34(12)1977-1983.