“TENNIS ELBOW”

By

“MAHIDA MEET MAGANLAL”

Project submitted to the

KAMDAR INSTITUTE OF PHYSIOTHERAPY

RAJKOT

In Partial fulfillment of

SIX MONTH ROTATARY INTERNSHIP

Under the guidance of

“Dr. Mira Tolia (MPT in Orthopaedic Conditions)”

1
 KAMDAR INSTITUTE OF PHYSIOTHERAPY
RAJKOT
CERTIFICATE BY THE GUIDE

This is to certify that this dissertation entitled “tennis

elbow” is bonafide project work done by Meet mahida was
completed under my supervision. I am satisfied with the
work presented by the candidate toward the partial
fulfilment of the requirement for the bachelor of
physiotherapy.

Signature of Guide
Name: Dr. Mira Tolia
Degree: MPT in Orthopaedic Conditions
Date:

2
Place: Rajkot
ENDORSEMENT BY THE PRINCIPAL

This is certifying that the project work entitles “tennis

elbow” is submitted by meet mahida. Under the guidance
of Dr. Mira Tolia assistant professor, Kamdar institute of
physiotherapy College, Rajkot.

Signature of the In-charge Principal

Name: Dr.Neeta Padmani Degree:
MPT in Ortho and Sports Date:
Place: Rajkot

3
 DECLARATION BY THE CANDIDATE

I hereby declare that this thesis entitles “tennis elbow” a

bonafide and genuine project work carried out by me under
the guidance of Dr Mira Tolia, Dr Neeta Panmani.

Signature of candidate
Meet mahida
Date:
Place: Rajkot

4
 ACKNOWLEDGEMENT

I am grateful to the god and to my family who gave me the

opportunity to undergo the bachelor program. They have
been my constant motivation throughout the course. I extend
my sincere thanks to the Dr Mira Tolia and Dr Neeta
Padmani who allowed me to do my project. I am privileged
to complete my project work under guidance of Dr Mira
Tolia MPT in Orthopaedic
Condition professor at Kamdar Institute of Physiotherapy.
I am extremely thankful for her constant encouragement and
inspiration during the internship.
I would also like to express my heartfelt thanks and gratitude
to my co-guide The Principal Dr Neeta Padmani MPT
Ortho & Sports at Kamdar Institute of
Physiotherapy. For their diligent guidance and advice.
I would also like to express my thanks to hatkes
multispeciality hospital - junagadh.
My sincere thanks to all the contributors whose names I
have not mentioned although they all deserve my gratitude.
Last but not the least I would like to thanks my all subjects
of my study for their wholehearted participation and
cooperation without whom the study may not have been
possible.

MEET MAHIDA
INDEX

1.ANATOMY OF ELBOW JOINT......................................................................................... 7

Features..................................................................................................................... ..................7

5
Articular Surfaces..................................................................................................................... .8
Ligaments.................................................................................................................... ............... 9
Relation..................................................................................................................... ................12
Blood Supply............................................................................................................................ 12
Nerve Supply................................................................................................................. ........... 13
Movements................................................................................................................................14
Carrying Angle........................................................................................................................ .15
2.TENNIS ELBOW (lateral epicondylitis)...........................................................................16
CLINICAL FEATURES.........................................................................................................17
TREATMENT.................................................................................................................... ......18
❖ Conservative treatment.................................................................................................... 18
❖ Operative treatment......................................................................................................... 20
Prevention of further damage:............................................................................................... 23
Restoration:................................................................................................................. .............24
REFRENCE..................................................................................................................... ........ 25

6
ANATOMY OF ELBOW JOINT

Features

⚫ The elbow joint is a hinge variety of synovial joint between the lower end of
humerus and the upper ends of radius and ulna bones.

⚫ Elbow joint is the term used for humeroradial and humeroulnar joints. The
term elbow complex also includes the superior radioulnar joint also.

7
Articular Surfaces

⚫ Upper

The capitulum and trochlea of the humerus.

The coronoid fossa lies just above the trochlea and is designed in a manner that
the coronoid process of ulna fits into it in extreme flexion. Similarly the radial
fossa just above the capitulum allows for radial head fitting in the radial fossa in
extreme flexion.

⚫ Lower,

i. Upper surface of the head of the radius articulates with the capitulum.

ii. Trochlear notch of the ulna articulates with the trochlea of the humerus
.
The elbow joint is continuous with the superior radioulnar joint. The
humeroradial, the humeroulnar and the superior radioulnar joints are together
known as cubital articulations.
Ligaments

1. Capsular ligament: Superiorly , it is attached to the lower end of thehumerus

in such a way thatthe capitulum, the trochlea, the radial fossa, the coronoid fossa
and the olecranon fossa are intracap srtlar. lnfer omedially, it is attached to the
margin of the trochlear notch of the ulrra except laterally; inferolaterally , it is
attached to the annular ligament of the superior radioulnar joint. The synovial
membrane lines the capsule and the fossae, named above. The anterior ligament,
and the posterior ligament are thickening of the capsule.

8
2 The ulnar collateral ligament

is triangular in shape . Its apex is attached to the medialepicondyle of the

humerus, and its base to the ulna. The ligament has thick anterior and posterior
bands:These are attached below to the coronoid process and the olecranon
process respectively. Their lower ends are joined to each other by an oblique
band which gives attachment to the thinner intermediate fibres of the ligament.
The ligament is crossed by the ulnar nerae and it gives origin to the flexor
digitorum superficialis. It is closely related to the flexor carpi ulnaris and the
triceps brachii.

9
3 The radial collateral or lateral ligament:

It is a fan-shaped band extending from the lateral epicondyle to the annular

ligament. It gives origin to the supinator and to the extensor carpi radialis brevis
.

10
Relation

⚫ Anterioily; Brachialis, median nerve, brachial artery and tendon of biceps

brachii .

⚫ Posteriorly; Triceps brachii and anconeus.

⚫ Medially; Ulnar nerve, flexor carpi ulnaris and common flexors.

⚫ Laternlly: Supinator, extensor carpi radialis brevis and other common

extensors.

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Blood Supply

⚫ From anastomoses around the elbow joint

Nerve Supply

⚫ The joint receives branches from the following nerves.

i. Ulnar nerve.

ii. Median nerve

. iii. Radial nerve. iv. Musculocutaneous nerve through its
branch to the brachialis.

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Movements

1 Flexion is brought about by:

i. Brachialis. ii. Biceps

brachii. iii. Brachioradialis.
2 Extension is produced
by:

i. Triceps brachii. ii.

Anconeus.

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Carrying Angle

The transverse axis of the elbow joint is directed medially and downwards.
Because of this the extended forearm is not in straight line with the arm, but
makes an angle of about 13 degrees with it. This is known as the carrying angle.
The factors responsible for formationof the carrying angle are as follows.

a. The medial flange of the trochlea is 6 mm deeper than the lateral flange.
b. The superior articular surface of the coronoid process of the ulna is placed
oblique to the long axis of the bone.

The carrying angle disappears in full flexion of the elbow, and also during
pronation of the forearm. The forearm comes into line with the arm in the
midprone position, and this is the position in which the hand ismostly used. This
arrangement of gradually increasing carrying angle during extension of the
elbow increases the precision with which the hand (and objects held in it) can be
controlled

TENNIS ELBOW (lateral epicondylitis)

⚫ Tennis elbow is a common entity characterized by pain and tenderness at the

common origin of the extensor group of muscles of the forearm. .

14
⚫ It is an extra-articular condition believed to be caused by strain or incomplete
rupture of the forearmextensor muscles or aponeurotic fibres at their origin,
respectively.

⚫ It is called tennis elbow because it was thought to be caused by an awkward

stroke during the game of tennis. However, it is usually an overuse injury in the
day- to-day activities of pulling, lifting, pushing, etc.

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 CLINICAL FEATURES

⚫ One finds tenderness, precisely localised to the lateral epicondyle of the

humerus. Pain is aggravated by putting the extensor tendons to a stretch; for
example, by palmar-flexing the wrist and fingers with the forearm pronated.
Elbow movements are normal. X-ray does not reveal any abnormality.

16
 Symptoms
The pain associated with tennis elbow may radiate from the outside of your elbow
into your forearm and wrist. Pain and weakness may make it difficult to:

Shake hands or grip an object

Turn a doorknob
Hold a coffee cup

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 Causes
Tennis elbow is an overuse and muscle strain injury. The cause is repeated
contraction of the forearm muscles that you use to straighten and raise your hand
and wrist. The repeated motions and stress to the tissue may result in a series of
tiny tears in the tendons that attach the forearm muscles to the bony prominence
at the outside of your elbow.

As the name suggests, playing tennis — especially repeated use of the backhand
stroke with poor technique — is one possible cause of tennis elbow. However,
many other common arm motions can cause tennis elbow, including:

Using plumbing tools

Painting
Driving screws
Cutting up cooking ingredients, particularly meat
Repetitive computer mouse use

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 Risk factors

Factors that may increase your risk of tennis elbow include:

Age. While tennis elbow affects people of all ages, it's most common in adults
between the ages of 30 and 50.
Occupation. People who have jobs that involve repetitive motions of the wrist
and arm are more likely to develop tennis elbow. Examples include plumbers,
painters, carpenters, butchers and cooks.
Certain sports. Participating in racket sports increases your risk of tennis elbow,
especially if you employ poor stroke technique

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 Diagnosis

During the physical exam, your doctor may apply pressure to the affected area
or ask you to move your elbow, wrist and fingers in various ways.

In many cases, your medical history and the physical exam provide enough
information for your doctor to make a diagnosis of tennis elbow. But if your
doctor suspects that something else may be causing your symptoms, he or she
may suggest X-rays or other types of imaging tests.

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 self-care measures:
Rest. Avoid activities that aggravate your elbow pain.
Pain relievers. Try over-the-counter pain relievers, such as ibuprofen (Advil,
Motrin IB) or naproxen (Aleve).
Ice. Apply ice or a cold pack for 15 minutes three to four times a day.
Technique. Make sure that you are using proper technique for your activities and
avoiding repetitive wrist motions.

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s
TREATMENT

❖Conservative treatment

⚫ The treatment consists of rest and trying to avoid the movements that cause
pain.

⚫ NSAIDs and a tennis elbow splint are used for pain relief

⚫ Local injection of hydrocortisone with local anaesthetic solution relieves

pain in majority of cases.

1. Cryotherapy: Ice pack for 30 min or ice massage for 7 min over the painful
area of entire muscle belly
.
2. Supportive measures: Initially, rest with a splint holding wrist in mild degree
of extension and sling with elbow in flexion and forearm in supination.
Posterior slab can also be given for the first 2–3 weeks. Unfortunately, this is
usually not done and the arm is allowed free movements which delay the
recovery.

3. Electrical stimulation: Sinusoidal stimulation for 20 minwith arm in elevation

relieves muscle spasm, prevents formation of adhesions and reduces oedema.

4. Iontophoresis: It can help in reducing pain and inflammation.

5. Diapulse, ultrasonics, TENS: These can be effective in controlling pain and

inflammation. Ultrasonography with hydrocortisone cream of 0.05%

22
 concentration as a coupling agent has been reported as a useful modality
(Hayden, 1972). Binder et al. (1985) suggested that ultrasound therapy
enhanced recovery in 63% cases. Review by Labelle (1992), Wright and
Vicenzeno (1997) however suggested that ultrasound provides little benefit
beyond that of a placebo.

6. Gentle effleurage and kneading during the first 2 weeks.

7. Gentle active movements of elbow, wrist and hand and isometrics at the end
of each range, if these are not painful, should be carried out with emphasis on
the wrist extensors.

8. Mild resistive exercises: Self-controlled resistive exercises by using the good

arm to resist the movements of wrist extension, radial deviation, finger flexion
and forearm supination should be initiated.

9. Vicenzino and Wright (1995), Brien and Vicenzino (1998) and Kavanagh
(1999) demonstrated improvement in both pain and function following
treatment with Mulligan’s lateral glide treatment.
❖ Operative treatment

⚫ In rare instances, surgery is indicated in resistant cases not responding to

conservative treatment. The extensor muscles are stripped from their origin,
i.e., lateral epicondyle, and are allowed to fall back.

⚫ An above-elbow slab with elbow in 90 degrees flexion is given for a period

of 10 days postoperatively.The elbow is then mobilized.

⚫ Trial of resistive exercises could be given with 1 lb or 0.5 kg dumbbell, and

gradually progressed to 2 lbs, 3 lbs or 1.5–2 kg dumbbells. The aim is to
achieve 15 repetitions of each movement without pain.

⚫ Patients with articular involvement respond with difficulty and usually need
prolonged rest.

⚫ Active movement is begun only after 3–4 weeks, if not painful.

Manipulation could be effective in cases where pain is provoked with active
use of extensor muscles by Mills manoeuvre (1937).

⚫ However, manipulation is contraindicated in case of pain at rest, stiffness

after rest and fibrositis.
⚫ Physiotherapy following surgery

1. Measures to reduce pain and inflammation.

23
2. Limb elevation and speedy as well as sustained active movements to the joints
free of immobilization. When mobilization is allowed (1 week)

3. Begin with slow relaxed full ROM passive movements tothe elbow, forearm
and wrist.

4. Shoulder and shoulder girdle should be mobilized to full ROM to avoid

adhesive capsulitis.

5. Begin with gradual active-assisted exercises and progress to self-resistive

techniques. Ultrasonics, TENS, diapulse can be used as adjuncts to reduce
pain.

6. Functional movements, carefully avoiding repeated supination, wrist

extension and strong grip.

7. Progress gradually to PRE. By 5–6 weeks, functionally painless elbow,

forearm and wrist movements should be regained

24
 Physiotherapeutic management

⚫ Physiotherapy plays an important role in the management of ‘tennis elbow’.

Preventive management:

⚫ Repeated forceful jerky movements to the common origin of extensor group

of muscles are the main cause.

⚫ Activities like wringing washed clothes, using a wrench, tightening a screw

and even a vigorous hand-shake should be avoided. Mechanical professions
and sports involving repetition of these movements are more prone to getting
tennis elbow.

⚫ Similarly, repeated supination using heavy rackets or weights should also

be discouraged

⚫ Proper conditioning and specific regime of strengthening exercises to the

extensor carpi radials longus and brevis as well as supinator forms the basis of
preventive programme.

⚫ Generalized strengthening of the common extensor group and avoiding

improper strain because of wrong attitudes in the game, e.g., top spine back
hand, or playing tennis with a small handle racket.
Prevention of further damage:

It is important to prevent further damage and thereby develop a chronic tennis

elbow.

1. Adequate care during the acute phase, resting the elbow joint with proper
support.

2. Instructing and guiding the patient against repetitive stretching or trauma to

the affected muscles by avoiding movements of supination, wrist extension,
radial deviation and tight grips.

25
3. Avoiding hasty mobilization: Early active movement causes repeated
breakdown in the formation of scar tissue which subsequently prolongs the
inflammatory reaction and leads to the formation of adhesions.

26
Restoration:

⚫ For the restorative programme to be effective, it is absolutely essential for

the physiotherapist to carefully evaluate the exact nature of involvement.

1. Strain and tear of muscle: Tenderness will be present at the musculotendinous

junction of the extensor carpi radialis brevis.

2. Epicondylitis: Partial tear of the tendon at their origin,with lesion in the

subtendinous space. Tenderness is felt exactly over the lateral epicondyle.
Granulation tissue formation as well as adhesions may be present.

3. Bursitis: Develops a bursa in the subtendinous space.

4. Articular involvement: Painful joint movement.

27
5.
1.Wrist Extension Stretch
____________________________________________________________
Equipment needed: None
• Additional instructions:
This stretch should be done throughout the day, especially before activity. After
recovery, this stretch should be included as part of a warm-up to activities that
involve gripping, such as gardening, tennis, and golf. Step-by-step directions

• Straighten your arm and bend your wrist back as if signaling someone to “stop.”

• Use your opposite hand to apply gentle pressure across the palm and pull it
toward you until you feel a stretch on the inside of your forearm.

• Hold the stretch for 15 seconds. • Repeat 5 times, then perform this stretch on
the other arm

28
(1) wrist extension stretch

(2) wrist flexion extension

29
2. Wrist Flexion Stretch
_________________________________________________________
Equipment needed: None

Additional instructions: This stretch should be done throughout the day,

especially before activity. After recovery, this stretch should be included
as part of a warm-up to activities that involve gripping, such as
gardening, tennis, and golf. Step-by-step directions

• Straighten your arm with your palm facing down and bend your wrist
so that your fingers point down.

• Gently pull your hand toward your body until you feel a stretch on the
outside of your forearm.

• Hold the stretch for 15 seconds.

• Repeat 5 times, then perform this stretch on the other arm.

3. Wrist Extension (Strengthening)

____________________________________________________

Equipment needed: Dumbbell hand weights (1 lb., 2 lbs., 3 lbs.)

Additional instructions: This exercise should be performed in stages. Begin

each stage with no

weight. When you are able to complete 30 repetitions on 2 consecutive days

with no increase in

pain, move forward in the program by increasing weight (begin with 1lb.,
advance to 2 lbs., end
with 3 lbs.).

30
Stage 1: Bend your elbow to 90 degrees and support your forearm
on a table with your wrist placed at the edge.
Stage 2: Straighten your elbow slightly. Continue to support your
arm on the table.
Stage 3: Fully straighten your elbow and lift your arm so that it is
no longer supported by the table.
Step-by-step directions to be followed for each stage

• With palm down, bend your wrist up as far as possible.

• Hold up for 1 count, then slowly lower 3 counts.

• Begin without using a weight and increase the repetitions until you
can complete 30.

• When you can perform 30 repetitions on 2 consecutive days

without increasing pain, begin performing the exercise using a 1 lb.
weight.

• Follow the same steps above to continue to increase repetitions

and weight until you are using a 3 lb. weight and can perform
30 repetitions on 2 consecutive days without increasing pain

31
 fig 3

fig 3

32
 4. Wrist Flexion (Strengthening)
____________________________________________
_

Equipment needed: Dumbbell hand weights (1 lb., 2 lbs.,

3 lbs.)

Additional instructions: This exercise should be

performed in stages. Begin each stage with no

weight. When you are able to complete 30 repetitions on

2 consecutive days with no increase in

pain, move forward in the program by increasing weight

(begin with 1lb., advance to 2 lbs., end

with 3 lbs.).

Stage 1: Bend your elbow to 90 degrees and support your

forearm

on a table with your wrist placed at the edge.

Stage 2: Straighten your elbow slightly. Continue to

support your

arm on the table.

Stage 3: Fully straighten your elbow and lift your arm so

that it is

no longer supported by the table.

Step-by-step directions to be followed for each stage

• With palm up, bend your wrist up as far as possible.

• Hold up for 1 count, then slowly lower 3 counts.

• Begin without using a weight and increase the

repetitions until you

can complete 30.

33
• When you can perform 30 repetitions on 2 consecutive
days=

without increasing pain, begin performing the exercise

using a 1 lb.

weight.

• Follow the same steps above to continue to increase

repetitions

and weight until you are using a 3 lb. weight and can
perform

30 repetitions on 2 consecutive days without increasing

pain.

5. Forearm Supination & Pronation (Strengthening)

_____________________________________
Equipment needed: Dumbbell hand weights (1 lb., 2 lbs.,
3 lbs.)

Additional instructions: This exercise should be

performed in stages. Begin each stage with no

weight. When you are able to complete 30 repetitions on

2 consecutive days with no increase in

pain, move forward in the program by increasing weight

(begin with 1lb., advance to 2 lbs., end

with 3 lbs.).

Stage 1: Bend your elbow to 90 degrees and support your

forearm

on a table with your wrist placed at the edge.

Stage 2: Straighten your elbow slightly. Continue to

support your

arm on the table.

34
Stage 3: Fully straighten your elbow and lift your arm so
that it is

no longer supported by the table.

Step-by-step directions to be followed for each stage

• Begin with palm facing the side. Slowly turn the palm
facing up.

• Slowly return to the start position, then slowly turn the

palm

down.

• Slowly return to start position. This completes one

repetition.

• Begin without using a weight and increase the

repetitions until you

can complete 30.

• When you can perform 30 repetitions on 2 consecutive

days

without increasing pain, begin performing the exercise

using a 1 lb.

weight.

• Follow the same steps above to continue to increase

repetitions

and weight until you are using a 3 lb. weight and can
perform

30 repetitions on 2 consecutive days without increasing

pain.

35
 fig 5

Stress Ball Squeeze

36
7. Finger Stretch

37
 6. Stress Ball Squeeze
____________________________________________

Equipment needed: Rubber stress ball

Additional instructions: This exercise should be
performed after completing the above staged
strengthening
exercises. Your arm and elbow position for this exercise
should match the stage you are completing.

7. Finger Stretch
_________________________________________________

Equipment needed: Elastic band

Additional instructions: This exercise should
be performed after completing the above staged
strengthening exercises. Your arm and elbow position for this
exercise should match the stage you
are completing

38
39
 REFRENCE

1. NATARAJAN'S Textbook of Orthopaedics and Traumatology

2. BD Chaurasiya Human Anatomy

3. Orthopedic Physical Assessment 7th Edition

4. Jayant Joshi Essentials Of Orthopaedics

5. Essential Orthopaedics Maheshwari

40