Introduction
Tennis, a sport synonymous with grace and precision, also carries its share of physical challenges, particularly concerning the elbow. Recognising the symptoms and early signs of conditions such as tennis elbow, golfer’s elbow, and UCL insufficiency is crucial for prompt treatment and prevention of further complications.
A comprehensive understanding of elbow injuries and their prevention empowers tennis players to maintain peak performance and enjoy the sport for many years. By taking proactive steps, players can safeguard their elbows and continue to thrive on the court.
1 - Lateral Epicondylitis (Tennis Elbow)
Lateral epicondylitis, commonly known as tennis elbow, manifests as pain around the outer aspect of the elbow. In addition to discomfort experienced during and after tennis matches, individuals afflicted with this condition may encounter difficulties such as weakened grip strength and pain during everyday activities like shaking hands, lifting a cup of coffee, turning doorknobs, and shaving [1].
Several factors contribute to the development of tennis elbow. These include advancing age, with the condition being more prevalent in individuals older than 35 years [4]. Furthermore, engaging in high levels of physical activity, defined as playing tennis three times a week or more, increases the risk of lateral elbow tendinopathy. This condition is particularly common among tennis players aged 35 to 50 years, with 45% of daily players and 20% of those playing twice weekly experiencing symptoms at various stages [4].
Tennis elbow primarily affects the extensor carpi radialis brevis muscle (Figure 1) and is often the result of microtrauma stemming from repetitive backhand strokes, particularly those executed with a one-handed technique [5]. It is estimated to affect up to 50% of tennis players, with a higher prevalence observed among recreational players [2]..
Figure 1. Extensor Carpi Radialis Brevis Muscle |
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2 - Radial Nerve Entrapment
The radial nerve, a critical component of the arm's neural network, branches just below the elbow's lateral region into the posterior interosseus nerve. However, it is susceptible to compression as it traverses the arcade of Frohse within the supinator muscle, responsible for forearm supination. This compression can lead to symptoms reminiscent of tennis elbow, causing discomfort and functional limitations in affected individuals.
Figure 2. Posterior interosseus nerve passing the supinator muscle | |
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3 - Medial Epicondylitis (Golfer’s elbow)
Medial epicondylitis, commonly known as golfer's elbow, presents a specific set of challenges for tennis players, particularly those engaged in high-level competition. The patient usually complains about pain of the elbow distal to the medial epicondyle of the humerus with radiation up and down the arm, most common on the ulnar side of the forearm, the wrist and occasionally in the fingers.
This condition typically involves the pronator teres and flexor carpi radialis muscles (Figure 3) and often results from repetitive microtrauma sustained during serves and forehand strokes [5,6].
The condition is characterised by degenerative changes in these muscles, often attributed to repetitive stress and muscular overload induced by overhead serves. Professional players, in particular, are prone to developing medial epicondylitis due to their tendency to excessively flex the wrist and pronate the forearm during strokes [5]. This condition is less common in novices [2].
Contributing factors are excessive wrist snap on serves and forehand strokes, open-stance hitting, and short-arming strokes [2]. Pain typically occurs during the late cocking phase of serving or the early acceleration phases of serving and forehand strokes [5].
Figure 3. Pronator Teres and Flexor Carpi Radialis |
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4 - Ulnar Collateral Ligament Insufficiency
The ulnar collateral ligament (UCL), a critical stabiliser in the elbow, is composed of three distinct bands (Figure 4): the anterior oblique ligament, the posterior oblique ligament and the small transverse ligament [6]
The anterior oblique ligament is particularly strong, remaining taut throughout the entire range of elbow flexion and is the primary constraint against valgus stress on the elbow.
The posterior oblique ligament becomes taut only during flexion and is lax during extension, thus not playing a primary role in elbow stability.
The transverse collateral ligament, which stabilises the elbow against varus stress, is not clinically significant due to its weak fibres [5,6].
Figure 4. Ulnar Collateral Ligaments |
1 = anterior oblique ligament (AOL); 2 = posterior oblique ligament (POL); 3 = transverse band. [6] |
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5 - Posterior Tennis Elbow
Posterior tennis elbow, also known as posterior olecranon impingement or hyperextension elbow injury, is a condition often associated with aggressive elbow extension during the follow-through phase of tennis strokes. This repetitive and forceful motion can lead to the olecranon impinging on the posterior aspect of the humerus, resulting in a variety of complications [6]
One common issue is triceps tendinopathy, a condition where the tendon of the triceps muscle becomes irritated and inflamed due to the constant stress and friction against the humerus. This inflammation can lead to pain, swelling, and reduced strength in the triceps muscle, significantly impacting a player's ability to perform optimally [1]
Moreover, repeated hyperextension of the elbow can lead to the formation of osteophytes, or bone spurs, on the olecranon. These osteophytes develop as a response to the chronic stress placed on the bone when the olecranon is forcefully driven into the olecranon fossa. The presence of osteophytes can further exacerbate pain and restrict the range of motion in the elbow, creating a cycle of injury and inflammation [6]
Conclusion
Elbow injuries are a significant concern for tennis players, impacting both performance and long-term health. By understanding the biomechanics of the elbow, mastering proper techniques, and making informed equipment choices, players can reduce their risk of injury. The importance of a holistic approach that includes examining the kinetic chain and addressing potential nerve entrapments cannot be overstated. Additionally, recognising the symptoms and early signs of conditions such as tennis elbow, golfer’s elbow, and UCL insufficiency is crucial for prompt treatment and prevention of further complications.
Incorporating preventative strategies, such as proper warm-ups, strength training, and flexibility exercises, can also play a pivotal role in maintaining elbow health.
References
1. Cassell E, McGrath A. Lobbing injury out of tennis: a review of the literature. Monash University Accident Research Centre. 1999 Feb;(144).
2. Dines JS, Bedi A, Williams PN, Dodson CC, Ellenbecker TS, Altchek DW, et al. Tennis Injuries: Epidemiology, Pathophysiology, and Treatment. Journal of the American Academy of Orthopaedic Surgeons. 2015 Mar;23(3):181–9.
3. Di Giacomo G, De Gasperis N, Costantini A. Tennis: Epidemiology and Injury Mechanism. In: Volpi P, editor. Arthroscopy and Sport Injuries [Internet]. Cham: Springer International Publishing; 2016 [cited 2024 Jan 30]. p. 19–23. Available from: https://link.springer.com/10.1007/978-3-319-14815-1_3
4. Renström P, editor. Handbook of sports medicine and science. Tennis. Malden, MA: Blackwell Science; 2002. 318 p. (Handbook of sports medicine and science).
5. Patel H, Lala S, Helfner B, Wong TT. Tennis overuse injuries in the upper extremity. Skeletal Radiol. 2021 Apr;50(4):629–44.
6. Eygendaal, D. and Safran, M.R., 2006. Postero-medial elbow problems in the adult athlete. British Journal of Sports Medicine, 40(5), pp.430–434. https://doi.org/10.1136/bjsm.2005.025437.
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