2. What is tennis elbow?
• Tennis elbow/lateral epicondylitis is the tendinopathy of the
common extensor-supinator tendon.
• Lateral periepicondylar pain and tenderness that is
exacerbated by forceful repetitive wrist extension.
3.
4. History
• In 1883, H.P.Major noted that this condition commonly affected
tennis players, the complaint became popularly known as
‘tennis elbow’(Nirschl 1974).
• Seen in 13% of elite tennis players and 50% of non elite players.
• But 95% of cases occur in those who do not play tennis and are
associated with manual occupations.
5. Pathology
• Degenerative microtears in common extensor-supinator tendon
due to repetitive mechanical overload.
• The tendinous origin of Extensor carpi radialis brevis most
commonly affected.
• Microscopic feature of surgical specimen:
Hyaline degeneration
Fibroblastic and vascular proliferation- angiofibroblastic
hyperplasia
Microscopic calcification
6.
7. Etiology
• Tennis players: due to faulty playing techniques mostly a late
mechanically poor backhand.
• Non tennis players:
95% of cases seen
Housewives, carpenters, miners, drill workers, other sports.
Use of computer
8.
9. Clinical features
• Usually an Active individual of 30 or 40 years.
• Pain and tenderness over lateral epicondyle of elbow.
• Acute or insidious onset of pain.
• History of over use, involving forceful gripping, repetitive flexion-
extension at wrist or pronation-supination activity.
• Pain aggravated by movements like pouring out tea, turning stiff door
handle, shaking hands, lifting weights,etc.
• Elbow looks normal and flexion and extension are full and normal.
10. Physical Examination
• Localised tenderness at or just below the lateral epicondyle
• Cozen’s test: painful resisted extension of the wrist with elbow in full
extension elicits pain at the lateral aspect of elbow
• Mill’s test: Elbow held in extension ,passive wrist flexion and
pronation produces pain.
• Maudsley’s test: examiner resist the extension of third digit of hand ,
stressing the extensor digitorum muscle and tendon. A positive test is
indicated by pain over lateral epicondyle.
14. Differential diagnosis
• Radial tunnel syndrome: posterior interosseous nerve
entrapment between the fibres of supinator muscle. Clinically
pain will increase with resisted supination. Pain is located 3-
4cm distal to lateral epicondyle.
• Osteochondritis dissecans of the elbow: patient may
complaint of snapping or locking. Maximum tenderness found
posterior to lateral epicondyle.
15. Imaging
• Not routinely performed
• Diagnostic ultrasound features include:
In active severe disease- neovascularisation
Local fluid collection
In chronic cases- dystrophic calcification at tendon insertion
16. Conservative Treatment
• 90% of ‘tennis elbow’ will resolve spontaneously within 6-12 months.
• First step is to identify and restriction or modification of the activities which
cause pain.
• In acute stages use of ice pack, use of NSAIDS(preferably topical) can be
useful.
• Compression strap applied distal to bulk of extensor mass(to reduce
maximum contraction) is helpful. It is used only during aggravating activity.
• Injection of tender area with corticosteroids and local anaesthetic relieves
pain but is not curative.
• Physical therapy: ultrasound therapy, remedial exercises may be effective in
long term
20. Operative treatment
• Indicated in sufficiently persistent or recurrent cases usually after 6-
12 months of failed conservative management.
Options :
I. Open debridement of the diseased tissue of the ECRB
II. Percutaneous release
III. Arthroscopic debridement
27. Bibliography
• Apley’s system of orthopaedics and fracture, 9th edition
• Oxford Sports injuries by Michael Hutson and Cathy Speed
• Textbook of orthopaedics by John Ebnezar, 4th edition
• Essential handbook of practical orthopaedic examination by Kaushik
Banerjee, 4th edition
• Essential orthopaedics by Maheshwari, 5th edition
