American Family Physician

Tennis ElbowANTHONY E. FOLEY, M.D., Wright State University School of Medicine, Dayton, Ohio

The term "tennis elbow" usually refers tolateral epicondylitis, but the same symp-toms can be caused by pathologic pro-cesses in the elbow. In fact, most cases ofthis common condition are caused by occu-pational stress rather than racket sports.Patients complain of elbow pain when thewrist is extended against resistance or dur-ing repetitive actions with the wrist andelbow extended. The condition is thought tobe caused by a lesion at the origin of thecommon wrist extensor mechanism, at orvery near the lateral epicondyle of thehumerus. Differential diagnosis includes in-flammatory, arthritic and nerve entrapmentsyndromes. Prompt conservative treatmenthas a high success rate. Patient education,use of a tennis-elbow band and physicaltherapy play key roles in the management ofacute symptoms and in the prevention ofrecurrence. Surgical intervention is requiredonly when other treatment fails.

The extensor muscles of the wrist originatein the lateral epicondyle and supra-condylar line of the humerus. The threewrist extensors that originate on the lateralside of the elbow are the brachioradialis,the carpi radialis longus and the carpiradialis brevis.' The term "tennis elbow"has been used since 1882 to describe painat or near the origin of the extensor carpiradialis brevis.^ The pain, however, is notrelated to tennis in at least 95 percent ofpatients.^ Participation in sports accountsfor most cases in younger patients, but inolder patients, tennis elbow is more com-monly related to occupation."^ The inci-dence of work-related cases has been esti-mated at 59 per 10,000 workers per year.̂

The etiology of the condition is un-known but probably comprises traction.

August 1993

repeated microtrauma and inflammation.''Direct trauma or systemic connective tis-sue disease is rarely implicated as a causeof tennis elbow.

Illustrative Case

A 42-year-old right-handed man, whoworked as an accountant, complained ofpain of two months' duration in his rightelbow. The pain was noticeable when hetyped on a computer but severe when helifted heavy manuals from a bookshelf. Heplayed no racket sport. During the pre-vious six months he had been remodelinghis home, hammering, sanding and usingvarious hand tools.

The only abnormality on examinationwas vague tenderness directly over andone inch distal to the right lateral epi-condyle. No swelling or crepitus of theelbow was noted, and the medial epi-condyle was not painful. Tinel's sign wasnegative, and paresthesia was not elicitedby resisted extension of the long finger ofthe right hand.

The patient was comfortable holding abook in his right hand while his elbowwas flexed at liis side and his forearm wassupinated. When the patient held the bookwith his forearm actively pronated, heimmediately felt pain in the right lateralepicondyle region and abducted the armwhile allowing the book to dip. Thismaneuver reproduced the symptoms heexperienced at work.

The clinical diagnosis was tennis elbow.After a splint was placed on the patient'sforearm, he was able to grasp the bookmuch more comfortably than before. Hewas instructed to wear the splint when

281

American Family Physician

Tennis Elbow

FIGURE 1. The wrist and elbow are extended against a lu.id, showing thelocation of the lateral epicondyle of Lhe humenis (A) and the location ofthe extensor carpi radialis brevis muscle (B).

txtensor carptradialis brevis

mFIGURE 2. Posterior aspect of right forearm,showing extensor carpi radinlis brevis and thearea of pain associated with tennis elbow.

working in his office or home, to avoid lift-ing and grasping objects when his forearmwas pronated and to lift objects with hiselbow closer to his body. The patient de-cided to arrange for help in remodeling hishouse. Ibuprofen was prescribed at adosage of 600 mg three times daily withmeals. Six weeks later the patient wasmuch improved.

Diagnosis

The illustrative case is typical in that thepatient played no racket sport and ac-quired his symptoms occupationally. Thesite of pain in teimis elbow has been local-ized to the attachment of the extensorcarpi radialis brevis mechanism to the dis-tal aspect of the lateral epicondyle {Figures1 and 2). Scarring and granulation arefound at this site in patients treated surgi-cally, but no single clinicopathologicprocess has been unequivocally identifiedas the cause of the pain.^

Tennis elbow occurs most often in whitemen between 30 and 60 years of age. Thedominant side of the body is more fre-quently affected. Tennis elbow is reported-ly rare in blacks." The reported duration ofsymptoms ranges from three weeks tothree and one-half years, with an averageduration of six to 12 weeks. Tennis elbowis usually a chronic condition by the timethe patient seeks medical treatment.

The diagnosis is clinical. No completelyreliable or pathognomonic sign exists.Tenderness usually occurs over the lateralepicondyle or one to two inches distally, orat both sites. The pain decreases grippingpower and can be provoked by resistingextension of the wrist." A "coffee-cup"sign has been described, in which painoccurs at the lateral epicondyle when thepatient picks up a full cup of coffee.'"

A heavy book (about 6 Ib) can be usedboth as an aid to diagnosis and for patienteducation on how to lift objects. Thepatient with tennis elbow can hold a bookwith little or no pain if the elbow is flexed

282 volume 48, number 2

American Family Physician

FIGURE 3. When a heavy book is held with the elbow flexed and adduct-ed, the patient with tennis elbow does not experience pain.

FIGURE 4. iiop) Gr.isping a heavy bonk while the forearm is pronatedcauses immediate pain in the elbow, followed quickly (bottom) by elbowabduction, allowing the book to dip below the level of the elbow.

TABLE 1

Differential Diagnosis of Tennis Elbow

NeuropathicRadial tunnel syndromeEntrapment of posterior interosseous nerveEntrapment oi musculocutaneous nerveEntrapment of median nerve (pronator syndrome)Ulnar entrapment syndromes

InflammatoryRadiocapiteliar arthritisSynovitisGouty arthritisJoint space infection

TraumaI^dial neck fractureDistal humerus fractureReferred painCervical radiculopathyShoulder arthritisCarpal tunnel syndromeAngina pectoris

OtherLateral epicondylitis (most common)Medial epicondylitisTumor (primary or secondary)Bone cyst

and adducted with the forearm supinated(Figure 3). However, when holding thebook with the forearin pronated, thepatient experiences immediate pain in thelateral epicondyle region, abducts theelbow and allows the book to dip belowthe level of the elbow {Figure 4).

The most common examination tech-nique is palpation at and just distal to theaffected lateral epicondyle while the ex-aminer resists the patient's wrist exten-sion. Because the extensor carpi radialisbrevis inserts on the third metacarpalbone, some examiners prefer to use resis-tance against extension of the third, orlong, finger rather than the entire wrist.This test (resisted wrist/finger extension),however, can produce variable temporaryparesthesia in patients with radial tunnelsyndrome. Passive pronation and supina-tion of the forearm and extension and flex-ion of the elbow do not cause pain inpatients with lateral epicondylitis.

Conditions that must be differentiatedfrom tennis elbow are listed in Table 1.The five possible nerve entrapment syn-

August 1993 283

American Family Physician

Tennis Elbow

Area of pain

Area of paresthesia

Area of pain

Site of entrapment

Posteriorinterosseous nerve

FIGURE 5. Entrapment sites of the radial nerve Ueft) and the posterior interosseous nerve {right) andareas of associated pain and paresthesia.

The Author

ANTHONY E. FOLEY, M.D.is assistant professor of family practice atWright State University School of Medicine,Dayton, Ohio, and a teacher in lamily practiceat St. Elizabeth Medical Center, Dayton. Dr.Foley graduated from the Ohio State Univer-sity College of Medicine, Columbus, and com-pleted a residency in family practice at theUniversity of Missouri-Columbia School ofMedicine, Columbia.

284

dromes present the greatest diagnosticchallenges."'-

•The radial nerve can become com-pressed in the radial tunnel as it courseslaterally around the posterior surface ofthe humerus and pierces the lateral mus-cular septum (Figure 5). Pain from radialnerve compression may be referred to thelateral epicondyle region, and paresthesiasmay occur in the distribution of the su-perficial radial nerve. With radial nervecompression, a Tinel's sign over the radial

volume 48, number 2

American Family Physician

Area of decreasedsensation

FIGURE 6. Entrapment sites of the musculocutaneous nerve Heft) and the median nerve (right) andassociated areas of pain and decreased sensation.

head is possible, as well as tenderness tomuscle palpation approximately 4 cm dis-tal to the lateral epicondyle. The mostcommon finding is pain when the arm issupinated against resistance while theelbow is extended. Weakness of full-fingerextension and limited extension of theelbow may be noted.

•The posterior interosseous nerve (deepbranch of the radial nerve) can becometrapped within the supinator muscle(Figure 5). Such entrapment produces weak-ness of fifth-finger extension and pain at

August 1993

the elbow, making the condition difficult todistinguish from radial tunnel syndrome.

• The musculocutaneous nerve can becompressed by the bicipital aponeurosisand tendon against the brachial fascia, re-sulting in pain in the anterolateral elbowand decreased sensation in the radial volarforearm (Figure 6).

•The median nerve can be compressedat four different sites in the forearm(pronator syndrome), producing pain inthe volar forearm that worsens with repet-itive use (Figure 6). Pain can be provoked

285

American Family Physician

Tennis Elbow

by resisting pronation or by resisting flex-ion at the proximal interphalangeal joint ofthe third finger.

•Tlie ulnar nerve can be trapped in theelbow or forearm, although the pain occursin the medial forearm or hand (Figure 7).

Tennis elbow usually causes no visibleswelling. If swelling is present, arthritis,synovitis, infection, trauma and tumorshould be diagnostic considerations.Inflammation can develop in the radio-capitellar bursa, as well as the synovialinsertion at the elbow. Gout can produce

FIGURE 7. Entrapment site ol tliu ulnar ner\uand area

286

swelling in the elbow." Joint space infec-tion and primary or metastatic tumors aredifferential possibilities but rarely aremanifested by point tendeniess at or nearthe lateral epicondyle.

Elbow pain can represent pain from cer-vical radiculopathy or carpal tunnel syn-drome."̂ Rarely, the pain of angina pectorisis referred to the elbow. A history offalling or trauma should elicit a search forfracture, especially of the radial neck.Lastly, medial epicondylitis produces painover the medial epicondyle of the hu-merus. Tine condition is known as golfer'selbow, although it also occurs in baseballpitchers and tennis players. This mis-nomer highlights the confusion caused byappending a sport's name to a medicalcondition.

Treatment

Patient education, protection of thepainful elbow and avoidance or modifica-tion of aggravating actions are critical fac-tors in the treatment of tennis elbowj''Treatment begins with teaching the patientlifting techniques that will protect theelbow. Lifting objects with the palm closeto the body is comfortable to patients withtennis elbow; lifting with the elbow extend-ed and forearm pronated is not.

A tennis-elbow band may be beneficial.To determine whether wearing a tennis-elbow band would be helpful in a partic-ular patient, a blood pressure cuff can beplaced on the affected forearm and in-flated to midway between systolic anddiastolic blood pressure, to simulate a ten-nis-elbow band. When the patient grasps abook (as previously discussed), a reduc-tion in discomfort would demonstrate theutility of the band. A tennis-elbow bandcould then be prescribed, to be worn dur-ing daytime hours {Figure 8).

Two general types of bands are avail-able: static and counterforce. The staticband wraps around the forearm and ap-plies equal pressure to all areas of the fore-

volume 48, number 2

American Family Physician

FIGURE 8. rUicement oi a tennis-elbow band, with the pad over the exten-sor surface of the forearm.

arm. The counterforce band applies mostof the tightness directly over the extensormechanism of the forearm.

In severe cases, instead of a forearmband, a cock-up splint can be placed at thewrist, to provide 20 degrees of extension.

FIGURE y. When trcL' ot pain, i\w pjtieiit begins strengthening the fore-arm, using a 1-lb weight.

August 1993

Splinting shortens the extensor muscula-ture and reduces the drag on the origin ofthe extensor brevis muscle at the lateralepicondyle.

A nonsteroidal anti-inflammatory drug(NSAID) is a rational therapy.'"^ Cortico-steroid injection may be helpful, especiallyif the patient has disabling pain at the timeof initial presentation or if symptoms donot respond to rest, banding and NSAIDtherapy. An injection of crystalline steroidand local anesthetic can be administeredwith a 25-gauge needle at the lateral epi-condyle and in several other sites, up toone inch distal to the epicondyle. Thistechnique spreads the medication andmay prevent corticosteroid-induced skinatrophy. The patient should be instructedto apply ice to the area after the injectionand to rest the elbow for two to threeweeks."'-'^ After injection, pain commonlyflares for several days. Postinjection appli-cation of ice may prevent this flare.

Rehabilitation

Rehabilitation is crucial to prevent re-currence of tennis elbow."*''̂ After the painhas subsided, the patient should beginperforming stretching exercises of theextensor forearm muscles. After passivestretching, the patient should begin per-forming strengthening exercises for theforearm muscles by using a 1-lb weight{Figure 9).

Strong consideration should be given toa formal rehabilitation program for pa-tients with lateral epicondylitis related tooccupational or sports activities. Strategiesmust be developed to avoid repeated fore-arm stress. An occupational program mayinvolve a physical therapist or an occupa-tional therapist, or both, as well as a work-site visit. For sports-related cases, the pro-gram may include consulting a tennisprofessional to correct faulty backhandtechnique or racket selection.

Finally, surgery plays a role in the treat-ment of unresponsive, disabling lateral

287

American Family Physician

Tennis Elbow

epicondylitis.^" Surgery may be consideredif one or more of the following conditionsexists; severe pain in the epicondylar areafor at least six months, no response to twoweeks of immobilization and no responseto two local injections of corticosteroids.

Several surgical techniques are available.One technique-" involves percutaneousrelease of epicondylar muscles. Anothertechnique^" is more extensive and aims notonly at releasing the origin of the extensorcarpi radialis brevis but also at excisingany inflamed or pathologic tissue. Surgeryhas a diagnostic as well as a therapeuticaspect, because pathologic processes suchas radial nerve entrapment may be discov-ered during surgery.

The author thanks Rick Berkey, coordinator of pho-tography services at St. Elizabeth Medical Center,Dayton, Ohio, for technical assistance.

REFERENCES

1. Hoppenfeld S, Hutton R. Physical examin-ation of the spine and extremities. New York:Appleton-Century-Crofts, 1976.

2. Burgess RC. Tennis elbow. [ Ky Med Assoc

3. Chop WM Jr. Tennis elbow. Postgrad Med1989;86:301-4,307-8.

4. Gellman H. Tennis elbow (lateral epi-condylitis). Orthop Clin North Am 1992;23:75-82.

5. Kivi P. The etiology and conservative treat-ment of humeral epicondylitis. Scand ]RehabU Med 1983;15:37-41.

6. Kamien M. A rational management of tenniseibuw. Sports Med 1990;9:173-91.

7. Doran A, Gresham GA, Rushton N, WatsonC. Tennis elbow. A clinicopathologic stxidy of22 cases followed for 2 years. Acta OrthopScand 1990;61:335-8.

8. Coonrad RW, Hooper WR. Tennis elbow: itscourse, natural history, conservative and sur-gical management. } Bone Joint Surg lAm|1973;55:1177-82.

9. Sheon RP, Moskowitz RW, Goldberg VM.Soft tissue rheumatic pain: recognition, man-agement, prevention. 2d ed. Philadelphia:Lea & Febiger, 1987.

10. Coonrad RW. Tennis elbow. Instr CourseLectl986;35:94-Un.

11. Morgan RF, Terranova W, Nichter LS,Edgerton MT. Entrapment neuropathies ofthe upper extremity. Am Fam Physician1985;31(I):123-34.

12. Gersner DL, Omer GE. Peripheral entrap-ment neuropathies in the upper extremity. JMusculoskeletal Med 1988;March: 14-29.

13. Wilson JD, ed, Harrison's Principles of inter-nal medicine. 12th ed. New York: McGraw-Hill 1991:1835.

14. Fillion PL. Treatment o( lateral epicondylitis.Am J Occup Tlier 1991;45:340-3.

15. Birrer RB, ed. Sports medicine for the primarycare physician. Norwalk, Conn.: Appleton-Century'-Crofts, 1984.

16. Athletic training and sports medicine.Chicago, 111.: American Academy of Ortho-paedic Surgeons, 1984.

\7. Millar AP. Sports injuries and their manage-ment. Baltimore: Williams & Wilkins, 1987.

18. Wood M, Knight NC. Tennis elbow: its clini-cal course, etiology and treatment. J ArkansasMed StK- ]989;85:499-500.

19. Prentice WE, ed. Rehabilitation techniques insports medicine. St. Louis: Times Mirror/Mosby College Publications, IWO.

20. Crenshaw AH, ed. Campbell's Operativeorthopaedics. 7th ed. St. Louis: Mosby, 1987.

288 volume 48, number 2