Avoiding or managing tennis elbow
Competitive Sport has been sidelined by COVID19 but there is suddenly a glimmer of hope for Victorians with a staged return to many sports over the coming weeks. Tennis is one of the first sports back in action with the resumption of small group coaching and whispers of return to Competition. As for all sports, players need to consider match fitness now and how their bodies will cope after such a long break.
An injury both notorious and feared among tennis players is tennis elbow. Known as lateral epicondylitis or lateral epicondylosis it’s better described as lateral elbow tendinopathy (LET). It’s slightly more common and protracted in women, peaks among 35-50 year olds and like many tendon injuries is usually a response to load. Simply put tendon injuries tend to travel along a trajectory of inflammation and pain in response to overload; without rest and early intervention this can result in microtearing within the tendon and more inflammation and pain. Then among the most stubborn and competitive players who continue to play on through severe pain this can result in partial or complete tearing within the common extensor tendon – usually the extensor carpi radialis brevis.
So what is the best advice for LET? Prevention and early intervention are key. Coaching can assist with technique modification and physiotherapy plays an important role in strength and conditioning of more proximal joints – shoulder and elbow – to reduce the loading of wrist extensors. But once the cycle of pain has set in we need to follow the latest evidence for management of LET.
Rest from activity and conservative therapy may include massage and dry needling for release of wrist extensors and reduction of pain. A strap or taping may help to offload the tendon, improve proprioception and reduce pain. But physiotherapy should most importantly include a specific evidence based exercise program for tendon loading to improve its chance of healing. Heavy/slow resistance for the wrist extensors is important and similar to other tendon loading programs that exist for Achilles or patella tendinopathy. And researchers have found combining isometric loading with a concentric/eccentric program superior, reflecting that in tennis the wrist is relatively fixed similar to an isometric hold1.
For stubborn and protracted cases of LET platelet rich plasma (PRP) injections may be an option to improve tendon healing. PRP injections are not a quick fix however and noticeable improvement from a single injection can take several months2-4. Cortisone injections may reduce pain and allow players to keep playing in the short term but without promoting tendon healing they likely worsen the condition in the long run4. Surgical debridement and tendon repair is another option but few good quality randomised controlled trials exist to support its efficacy or superiority over other conservative treatments5-6.
The up-shot then for your best return to tennis is to be match ready and prevent or reduce the risk of LET keeping you out of the game.
- Stasinopoulos, D., & Stasinopoulos, I. (2017). Comparison of effects of eccentric training, eccentric-concentric training, and eccentric-concentric training combined with isometric contraction in the treatment of lateral elbow tendinopathy. Journal of Hand Therapy, 30(1), 13-19.
- Glanzmann, M. C., & Audigé, L. (2015). Platelet-rich plasma for chronic lateral epicondylitis: Is one injection sufficient? Archives of Orthopaedic and Trauma Surgery, 135(12), 1637-1645.
- Mishra, A. K., Skrepnik, N. V., Edwards, S. G., Jones, G. L., Sampson, S., Vermillion, D. A., … Rettig, A. C. (2014). Efficacy of Platelet-Rich Plasma for Chronic Tennis Elbow: A Double-Blind, Prospective, Multicenter, Randomized Controlled Trial of 230 Patients. The American Journal of Sports Medicine, 42(2), 463–471. https://doi.org/10.1177/0363546513494359
- Ben-Nafa, W., & Munro, W. (2018). The effect of corticosteroid versus platelet-rich plasma injection therapies for the management of lateral epicondylitis: A systematic review. Sicot-j, 4
- Watts, A., Morgan, B., Birch, A., Nuttall, D., & Trail, I. (2020). Comparing leukocyte-rich platelet-rich plasma injection with surgical intervention for the management of refractory tennis elbow. A prospective randomised trial. Shoulder & Elbow, 12(1), 46–53. https://doi.org/10.1177/1758573218809467
- Bateman, M., Littlewood, C., Rawson, B., & Tambe, A. A. (2019). Surgery for tennis elbow: a systematic review. Shoulder & Elbow, 11(1), 35–44. https://doi.org/10.1177/1758573217745041