The document provides an extensive overview of lateral epicondylitis, commonly known as tennis elbow, including its definition, clinical anatomy, pathophysiology, and management strategies. It highlights the impact of the condition on athletes, particularly in racquet sports, and outlines rehabilitation phases, exercises, and treatment modalities aimed at pain relief and recovery. Additionally, the document discusses the biomechanics involved in tennis play and how improper techniques and equipment can contribute to the development of tennis elbow.

1. TENNIS ELBOW
Dr AMIT PRASHAR (PT)
MPT(SPORTS)
ISIC-IRS

2. INTRODUCTION
Lateral epicondylitis or tennis elbow is a common disorder
which significantly impacts
on the athletic population.[1 ]
Definition: It is usually defined as the pain over the lateral
epicondyle which is reproduced by digital palpation over the
lateral epicondyle, resisted wrist extension,
middle finger extension and gripping.[1 ]
• It effects approximately 4-7 per 1 000 individuals.[1 ]
• In Lancet in 1 882, Morris described epicondylitis in
athletes and called it “lawn tennis arm.” The term “lawn
tennis elbow” is attributed to Major in an 1 883 article in the
British Medical Journal. Since then, racquet sport athletes of
all kinds have been noted to be particularly susceptible to the
development of lateral epicondylitis.[2]
• It has been estimatedthat 1 0% to 50% of people who
regularly play tennis do develop tennis elbow at some time
in their career.[2]

4. Clinical Anatomy
Elbow
Joint
• Articular surfaces:
upper- the capitulum and trochlea of the
humerus
lower - upper surface of radius head
articulates with capitulum
trochlear notch of ulna articulates with
trochlea of humerus
• Ligaments- 1.capsular ligament
2.ulnar collateral ligament
3. radial collateral ligament

5. Anatomy of Elbow

6. • Muscles involved in Tennis elbow:[3]
1. ECRB- EXTENSOR CARPI RADIALIS
BREVIS(essential and universal lesioned)
2. EDC- EXTENSOR DIGITORUM
COMMUNIS
3. ECRL- EXTENSOR CARPI RADIALIS
LONGUS
4. ECU- EXTENSOR CARPI ULNARIS
• Capsular injury as well as thickening and
tearing of lateral ulnar collateral ligament
and radial collateral ligament have been
identified in association with severe
lateral epicondylitis.[3]

7. MUSCLE ORIGIN INSERTION FUNCTION
ECRB
Common
extensor
tendon
dorsal
aspect of
base of 3rd
metacarpal
bone
Extend the
wrist
EDC
Common
extensor
tendon
dorsum of
2nd through
5th digits
Extend the
wrist and
second
through 5th
digits at the
MCP joints
ECRL
Distal
aspect of
lateral
suprcondyla
r ridge of
humerus
dorsum of
base of 2nd
metacarpal
bone
Extends and
abducts the
wrist
ECU
Common
extensor
tendon and
dorsal
aspect of
mid ulna
Ulnar
aspect of
base of 5th
metacarpal
bone
Extends and
adducts the
wrist

8. PATHOPHYSIOLOGY
• Few inflammatory type cells are found in LE; instead, the condition is more
commonly characterised by fibroblast enlargement, an abundance of
disordered collagen, vascular element hyperplasia, and finally death and
extracellular matrix breakdown.[15]
• Nirschl defined four stages of damage caused by repetitive microtrauma
involved in LE: (1) initial inflammatory reaction; (2) angiofibroblastic
tendinosis, which refers to degenerative changes due to failure of a tendon
to heal properly with presence of active fibroblasts, vascular hyperplasia,
and production of disorganized collagen; (3) structural failure or rupture; and
(4) structural failure plus fibrosis, soft matrix calcification, and hard osseous
calcification.[15]
• The healing process and normal collagen synthesis may be hampered by
the absence of functioning cells. It has been proposed that this poor
recovery can result in tissue weakness and increased vulnerability to
damage.[15]

9. BIOMECHANICS
• Elbow biomechanics play important role in various sports that involve
throwing motions including baseball pitch, the football pass, the javelin
throw, the tennis serve, the cricket shot and many more
.
• The tennis serve is the most energy-demanding tennis motion, and has
been shown to comprise nearly 45-60% of all strokes performed in a
tennis match.[14]
• The elbow functions as link in kinetic chain of ground stroke or the
serve.[5]
• If energy transfer in one joint is not efficiently coordinated, subsequent
joints can easily become overloaded.[14]
• The elbow is towards the distal end of tennis kinetic chains,receiving
energy and force from more proximal links thereby adding more energy
and force and passing them on the wrist and racquet.[5]
• manipulating kinetic chain is key to reduce impact forces on more distal
joint which is often done by advance players.[14]

10. BIOMECHANICS OF TENNIS SERVE
• THERE ARE 8 STAGES-
1. BODY POSITIONING- set up the body for the force generation.
2. BALL RELEASE- tossing the ball and shoulder abduction 100 degrees.
3. LOADING- building power through the legs.
4. COCKING- Shoulder and pelvis tilt laterally spine move into
hyperextension,lateral flexion and ipsilateral rotation.
5. Acceleration- Transitioning into forward movement of serve.
6. Contact- Ball velocity is determined by shoulder internal rotation and
adduction.
7. Decelaration- eccentric contraction of post cuff, serratus, deltoid and
errector spinae.
8. Finish- complet stopping of movement,require lower limb extensor
eccentric force.

13. PATHOBIOMECHANICS
1. According to research, tennis play cause pain in lateral elbow due to
dynamic stablisation of the wrist, repetitive loading of tendons and muscle
activity.[13]
2. Ground strokes of tennis player shows most muscle activity of wrist
extensors and ECRB.[13]
3. One hand backhand stroke places greater strain on these tendons.[13]
4. During backhand strokes, wrist supination and elbow extension produce
more contact pressure between ECRB and capitulum leading to degenerative
process.[13]
5. The motions and forces produce repetitive tensile loads on the ligamentous
and muscular support systems around the elbow and compressive and shear
loads on the bony constraints.[6]
6. It has been suggested that double hand backstroke leads to decreased
occurance of tennis elbow because of decreased forces on the lead elbow at
ball impact.[5]

16. ETIOLOGY
• Eccentric loading of the forearm extensors
muscles, predominantly the ECRB.[7]
• faulty mechanics i.e leading with the elbow, off
centre hits in racquet sports, faulty one hand
backhand shot, faulty flick shot in cricket.[7]
• poorly fitted equipments i,e handle too small, bat
too heavy in case of cricket,string too tight.[7]
• age factor 30 to 50 years.[7]
• pathological cause- repetitive contraction of ECRB
results in microtearing with subsequent
degradation ,immature repair and due to unique
anatomic position the tendon has lack of
vascularity which further contributes to
degeneration.[4]

18. CLINICAL FEATURES
• Pain anterior or just distal to the lateral
epicondyle that may radiate into the
forearm extensors.
• pain initially subsides but becomes more
severe with repetition.
• pain increases with resisted wrist
extension.
• pain upon gripping or rotation
• pain upon backhand strokes

19. ASSESSMENT
1. Subjective assessment findings may include:
• Symptoms will be present on the dominant arm with which player
plays.
• Chief complain of pain on outer surface of elbow while performing
particular shots in their respective game like single backhand shot
and flick shot in cricket.
• History -
• Onset of pain 24-72 hours after provocative activity involving wrist
extension or backhand serve.
• pain that may radiate down forearm as far as the wrist and hand
and pain severity ranges from relatively trivial to almost
incapacitating that keep patient awake at night.
• Aggravation by hitting and griping activities and changes in
biomechanical factors e.g. new tennis racquet, wet ball, over
training, poor technique, shoulder injury[8]
• Relief by rest .

20. .
2. Objective assessment Include:
• Pain and point tenderness over lateral
epicondyle and/or 1-2 cm distal to
epicondyle on palpation
• MMT- Forearm extensors muscle
strength and grip strength is reduced.
• ROM- Significant reduction in ROM for
wrist flexion,extension,pronation and
supination.
• Pain and weakness on resisted wrist
extension.

22. • Functional assessment – By PTREE(
Patient rated Tennis Elbow Evaluation)
Questionnaire.[10]
• Special Test –
1. Cozen’s Test- Resisted wrist extension
test.
2. Mill’s Test- passive streching of wrist in
flexion and pronation.
3. Maudsley’s Test- resisting third digit of
hand while palpating the Lateral epicondyle.

23. Cozen’s test Maudsley’s test

24. Investigation-
• A plain X-ray (AP/Lateral)
• Ultrasound- may demonstrate degree of tendon
damage.
• MRI- for differential diagnosis

25. MANAGEMENT
OPERATIVE
MANAGEMENT
PT MANAGEMENT

26. Operative method
• Open surgery
• Arthroscopic surgery

27. Physiotherapy Management
• Modalities
• Cyriax physiotherapy
• Taping
• Exercises and return to sports
• Activity modifications

28. REHABILITATION STAGES[18]
STAGE 1- pain relief
STAGE 2- promotion of healing(consists of 4
phases)
• Phase 1- rehabilitatative exercise
• Phase 2- fitness exercise
• Phase 3- advanced rehabilitation
techniques
• Phase 4- control of abusive overload by
activity modification,bracing and proper
equipment selection.

29. REHABILITATION
STAGE
PROGRAM MODALITIES/INTERVENTION
STAGE 1
[PAIN RELIEF AND
INFLAMMATION
CONTROL]
Conditioning program
should include central
aerobic exercises to
enhance overall
circulatory flow.
Isometrics (30-
60)seconds in pain free
ROM.
CRYOTHERAPY- to slow the rate
of metabolic reaction,promote
vasoconstriction and decrease
swelling.
US- to promote healing
SHOCKWAVE THERAPY- to
relieve pain
High voltage electrical
stimulation- to control pain and
enhance tissue vascularity.
COUNTERFORCE BRACING-
Enables patient to initiate each
phase of exercise and return to
sport.
KINESIO TAPING- To give
controlled mobility
DTF- To reduce pain
.STAGE 2
[PROMOTION OF
HEALING]
Consists of exercises to
restore
strength,aerobics and
general cv conditioning

30. PHASE 1[ REHAB EXERCISE] - Isometrics[multiangle] with symptom
limited submaximal contraction.
- Initial isotonic exercises
- Flexibilty exercises[stretching]
PHASE 2[FITNESS EXERCISE] - Consists of general fitness and aerobic
exercises
PHASE 3[ADVANCE TRANSISTIONAL
STRENGTHENING AND
NEUROMUSCULAR CONTROL]
- Plyometrics with medicine ball(side
throws,chest passes)
- catching and throwing weighted
resistance
-theraband exercises
- shoulder stability exercises
- core strength training
PHASE 4[FORCE LOAD CONTROL AND
RETURN TO SPORT]
-Emphasis on warm ups and cool downs.
- adequate equipment
- sports specific drills

31. Modalities/Interventions
IN ACUTE PHASE OF INJURY-
• ICE- ice pack for 10 minutes help reduction in pain and in acute
condition.[19]
• ULTRASONIC THERAPY- 1 cm2 application area, at 1.5
W/cm2, 1 MHz frequency,continuous mode in painful area, 5
min once a day, 5 days a week[16]
• SHOCKWAVE THERAPY- 10-15 Hz,1.5-2.5 bar energy density,
2000 pulses, once a week for three sessions.[16]
• K- TAPING- Diamond taping method may be useful for reducing
pain and improving grip strength and functional performance[11]
• DRY NEEDLING- To release trigger points, to promote pain
relief.[12]

32. TRIGGER POINTS NEAR ELBOW
DRY NEEDLING
K TAPING FOR TENNIS ELBOW

33. CYRIAX TECHNIQUE
• Cyriax technique combines the use of deep
transverse friction (DTF) with Mill’s
manipulations in LET. Both treatment
components must be used jointly in the
sequence specified. Patient must follow the
protocol three times a week for four weeks.[11]
1. DTF[Deep Transverse friction]- it is to applied
trasversely to the specific tissue involved or 10
mins untill numbing effect is produced, every other
day at 28 hrs interval.

34. 2. Mill’s manipulation- It should be
performed immediately after DTF.
In this there is elongation of scar tissue by
rupturing adhesions within teno-oseous
junction

35. CYRIAX PT
DTF
MILL’S
MANIPULATION
.

36. TENNIS ELBOW EXERCISE PROGRAM[18]
PHASE 1A- isotonic exercise to 1.5 kg daily
Exercise for wrist flexion,extension,pronation,supination with elbow
bent to 90 degree and forearm supported.
(15 to 20 reps)*3 sets without resistance
- Increase 0.5 kg weight as progression and cut back to 15-20 reps* 2
sets.
-progress to 20 reps*3 sets.
- follow the same protocol while increasing weight from 1 kg till 1.5 kg
without aggravating the pain.
-progress to phase 2
PHASE 1B- 50 to 100 reps of squeezing the tennis ball and opening
the fingers againt rubberband throughtout day. Elbow is bent to 90
degrees.

37. .
• PHASE 2 Functional progression
Theraband and isokinetic exercise
1. 3*/week isotonics- 10 reps* 2 sets, gradually work towards straightening of elbow
progression when elbow becomes straight; increase resistance to 2kg
2. 3*/week isoflex wrist flexion, extension,ulnar and radial deviation, supination; work
towards 50 reps of each.
3. if access to isokinetic equipment-
2*/ week isotonics (elbow almost straight)
2*/ week isoflex/theratube
2*/ week isokinetics
- Continue squeezing and rubber band exercises throughout the day, but elbow just short
of full extension.
4. Shoulder stabilisation exercises.
5. Core strengthening training.
-PROGRESS TO NEXT PHASE WHEN COMFORTABLE AND PAIN FREE IN ALL
ACTIVITY WITH FULL ROM.
PHASE 3
- Maintenance exercises
- Continue end point exercise for isotonic and isoflex program 3*/ week

38. GENERAL STRETCHING AND STRENGTHENING EXERCISES
THERABAND EXERCISES

39. SHOULDER STABILISATION EXERCISES
WOBBLE BOARD SHOULDER
STABILITY EXERCISE
SWISS BALL SHOULDER
STABILITY EXERCISE
MEDICINE BALL BALANCE
SCAPULAR MUSCLE EXERCISE LAWN MOVER 151 DRILL

40. CORE STRENGTH TRAINING
Core strength training improves physical fitness of tennis players.

41. PLYOMETRICS

42. playing with counterforce brace on
Activity modification and equipments corrections

43. REFERENCES
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44. 11. Mehta J, et al. Effect of Taping on Pain, Grip Strength, and Function in Deskbound Workers
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45. THANKYOU