With the change of seasons and the excited pursuit of new activities that accompanies it, our sports rehabilitation clinic will see a rush of seasonal injuries like plantar fasciitis, IT band syndrome and the subject of this column, “tennis elbow.”
What is it?
Tennis elbow (TE), also known as lateral epicondylalgia, is a repetitive-stress injury affecting the muscles and tendons that attach to your lateral elbow. The bottom of your arm bone (the humerus) has two epicondyles (or bumps). If you stand upright with your arms straight and palms forward, the lateral epicondyle is the bump on the outside, about one finger’s width above the elbow crease.
The pain associated with TE is typically felt directly over the epicondyle or just below in the tendons that attach to it. Put simply, overuse and misuse may lead to micro-tearing of the tendons near the elbow attachment, resulting in pain and weakened tissue that time by itself does not resolve.
Who gets it?
Approximately 40 percent of tennis players, most commonly those in their 30s and 40s, will experience TE. Men and woman are affected almost equally.
Unsurprisingly, as a repetitive-stress injury, there is a link between playing time and incidence of TE; playing more than two hours a day doubles the risk for players over 40 and almost quadruples the risk for players under 40.
Interestingly, studies have shown an increasing incidence of TE in class A players compared to class C players. However, this is likely explained by the increased volume and intensity of play in higher-level athletes. Lending credence to the importance of form and technique is the finding that lower-class players have a higher recurrence of TE.
Can I prevent it?
There are a number of good prevention strategies to consider.
- Equipment. Throw out your Jimmy Connors-era racquet and invest in something lightweight and younger than the internet. Make sure the weight distribution in the racquet is proper. A racquet with a larger sweet spot may help. Make sure your handle size is appropriate for your grip.
- Have a coach look at your mechanics. Keeping your knees bent during an overhead serve, for example, can reduce strain on the shoulder and elbow.
- Get a structured warm-up plan in place, and be disciplined about following it.
- Recovery! Make sure your training regimen includes a recovery plan (this is more than just days off).
- Come into the season with some level of conditioning and avoid suddenly ramping up the intensity or volume of play.
- Repetitive-stress injuries are caused by overuse, misuse or a combination of the two. The most common misuse is ramping up volume at a rate that outpaces your body’s ability to adapt. While your body will adapt to slow, incremental increases in workloads, it will react—sometimes painfully—to sudden increases in those loads.
- Misuse may refer to a wonky grip or a hitch in your form due to an old injury.
- Complex and explosive athletic movements, like those required in tennis, require all parts of the biomechanical chain to be functioning at top level. Athletes with prior injuries or weaknesses in core or shoulder-girdle muscles are at increased risk of developing TE.
What to do about it once you get it
You’ve probably heard of the acronym RICE (Rest, Ice, Compression, Elevation). Well, rehab professionals now use another acronym: POLICE. Protection, Optimal Loads, Ice, Compression and Elevation.
With TE, the ICE is often less important than the POL.
“Protection” does not mean wrapping your arm in bubble wrap. Usually it refers to some modest equipment changes, grip modifications, the temporary use of a brace (such as a counterforce brace or strap) or temporarily modifying your game.
Some easy-to-follow advice that is appropriate for most people with TE is to avoid obvious stressors throughout the day; heavy gripping and twisting (e.g. opening a stuck jar) and lifting objects in a palm down position, especially with the elbow fully extended (e.g. pouring milk from a gallon jug) should be minimized.
Determining what constitutes an “optimal load” when battling TE includes two considerations: 1) Avoiding full fatigue during a single playing session and ensuring proper recovery between sessions, and 2) Introducing external loads through resistance training to strengthen the affected tissues between playing sessions.
While in rare and severe injuries full rest is required, in lesser injuries it can be counterproductive. Complete rest results in deconditioning of tissues, muscle atrophy and stiffness. Determining optimal loading for healing can prevent the athlete from yo-yoing back and forth, from overuse to complete rest and back again. This is not a recipe for success, yet we see it all the time!
If you find yourself popping a handful of Advil, slapping on some frozen peas and resolving to rest your arm for the week, rethink your strategy. This may result in a decreased pain in the short-term, but it will not fix the underlying pathology.
How long will I be out?
Tennis players of all ages and abilities would be well served to get screened by a sports physical therapist for common imbalances that predispose to injury, participate in an off-season conditioning program to ensure the optimal functioning of the entire body, and work with a tennis pro to correct issues with form. If, despite these precautions, TE sidelines you or interferes with your desired level of activity, especially those of you with performance goals in mind, consult with a sports physical therapist—and a tennis pro. (A quick aside: Most athletes with TE should avoid corticosteroid injections as they lead to delayed healing and an increased risk of recurrence in the long term.)
In the meantime, visit VASTA Sports for additional information on TE, including simple self-treatment strategies and research into emerging treatment options.
Tennis is a ‘lifetime’ sport, right? Let’s plan for the long haul. Happy spring.
Jeff Albertson is a sports physical therapist and the director of physical therapy at VASTA Performance Training and Physical Therapy. He can be reached by email. Jeff and his family live in Charlotte.