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Tennis Injuries

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on 11 December 2013

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Transcript of Tennis Injuries

Tennis elbow

Elizabeth Pedowitz
MSK Elective 2013


1. Overview
2. Etiology
3. Pathogenesis
4. Clinical features
5. Imaging
6. Treatment
7. Mount Sinai Partnership with USTA

Commonly known as "tennis elbow"
First described in med lit in 1873 by Runge
Actually a tendinosis, not "itis"
Common overuse injury in tennis
Lifetime incidence anywhere from 35-51% in rec tennis players(Pluim et al)
May develop from variety of activities involving excessive/repetitive use of forearm extensors
In UK affects 1-3% of pop. (Ahmad et al)
Usually 35-55yo, M=F
Generally self-limiting with natural history of 10-18 mos
Mount Sinai and the USTA
Previously considered to be tendinitis but now considered a tendinosis
Continuous stress to tendon that results in micro-tears of common extensor tendon
Degeneration major cause of tendinosis
Recent studies suggest other causes
Pain caused by increased NTs like glutamate and direct irritation (Waugh et al)
Reason why pts present with pain in regions distant to site of injury like neck?
Clinical Features
Tenderness and PTP of lateral epicondyle often radiating down forearm with common extensor muscles and sometimes into upper arm
Mild-severe, intermittent-constant
Differential Diagnosis
Cervical radiculopathy
Posterior interosseus n. entrapment (radial tunnel syndrome)
Radiocapitellar OA
Elbow overuse compensating for frozen shoulder
Inflamm of anconeus
Non-operative: 90% successful
Physiotherapy: ROM, eccentric strengthening, stretching
Counter force bracing: Elbow strap, clasp, or sleeve orthoses
NSAIDs and corticosteroid injxn
Operative: Only if sx not resolved with nonop tx after 6mos
Alternative methods:
Ultrasound-guided percutaneous needle tenotomy, prolotherapy, acupuncture, botulinum toxin, autologous blood injxn, platelet-rich plasma

Histological stages of tendinosis of elbow (Kraushaar et al)
1. Acute inflam response
2. Insult sustained-->fibroblasts, vascular hyperplasia, disorganized collagen (angiofibroblastic hyperplasia); hypercellularity= tendinosis
3. Cont. accumulation-->structural failure of tendon with partial or complete rupture
4. Tendon has stage 2/3 features with fibrosis, soft-martrix calcification within disorganized loose collagen, hard osseus calcification
Hard to make dx on this alone
Long-standing dz- prominence of bony epicondyle
Palpation: PTP at site of ECRB tendon insertion or more diffuse
Full active and passive at elbow usually;
Severe cases pain at limit of extension when forearm fully pronated
Special maneuvers:
Cozen's test: forearm pronated, radially deviated, and wrist extended apply a flexion force against pt resistance
Mill's test: passively pronating the forearm, flexing the wrist and extending the elbow
Maudsley's test: resisted 3rd finger extension
3-view elbow xray: exclude bony pathologies
Ultrasound: structural changes in affected tendons (thickening, partial tear at tendon origin, calcifications)
MRI: degenerative tissue, tears
Imaging doesn't necessarily correlate with clinical sx
PRP and Chronic Tennis Elbow
Outcomes followed for up to 24 wks-
Pain score improvement:
12 wks: PRP-treated reported improvement of 55.1% vs 47.4% in control group (p=.094)
24 wks: PRP-treated reported improvement of 71.5% vs. 56.1% in control (p=.027)
Elbow tenderness
12 wks: 37.4% in PRP group vs 48.4% in control (p=.036)
24 wks: 29.1% PRP vs 54.0% control (p<.001)
Success rate within 24 wks
83.9% in PRP vs 68.3% in control (p=.012)
Double-blind, prospective, multicenter,
controlled trial of 230 pts (Mishra, et al, 2013)
Abrams GD, Renstrom PA, Safran MR. Epidemiology of musculoskeletal injury in the tennis player. Br J Sports Med 2012;46:492–498

Ahmad Z, Siddiqui N, Malik SS, et al. Lateral epicondylitis: A Review of Pathology and Management. Bone Joint J September 2013 vol. 95-B no. 9 1158-1164

Kraushaar BS and Nirschl RP. Tendinosis of the elbow (tennis elbow). Clinical features and findings of histological, immunohistochemical, and electron microscopy studies. J Bone Joint Surg Am. 1999 Feb;81(2):259-78.

Marx R, Sperling J, Cordasco F. Overuse injuries of the upper extremity in tennis players.
Clin Sports Med 2001;20:439–51.

Mishra AK, Skrepnik NV, Edwards SG, et al. Platelet-Rich Plasma Significantly Improves Clinical Outcomes in Patients With Chronic Tennis Elbow. Am J Sports Med July 3, 2013

Nirschl R, Ashman E. Elbow tendinopathy: tennis elbow. Clin Sports Med 2003;22:

O’Young, BJ, Young, MA, and SA Stiens. Physical Medicine and Rehabilitation Secrets. 2008.

Perkins, RH, and D Davis. Musculoskeletal Injuries in Tennis. Phys Med Rehabil Clin N Am17 (2006) 609–631

Pluim, BM, Staal, JB, Windler, GE, et al. Tennis injuries: occurrence, aetiology, and prevention. Br J Sports Med 2006;40:415–423. doi: 10.1136/bjsm.2005.023184

van Rijn RM, Huisstede BM, Koes BW, et al. Associations between work-related factors and specific disorders of the shoulder--a systematic review of the literature. Scand J Work Environ Health. 2010 May;36(3):189-201.

Waugh EJ. Lateral epicondylagia or epicondylitis: what's in a name? J Orthop Sports Phys Ther, 2005, April: 35 (4).

Contributory Factors
Tennis (Marx et al and Nirschl et al):
Leading with elbow during backhand stroke and premature trunk rotation
Novice players w poor technique repetitively extend wrist
Age > 35
High activity: >3x/wk (>30min duration)
Work-related (van Rijn et al):
Handling tools >1kg, loads >20kg, >10x/day, and repetitive movements >2hrs

Jayanthi N, Subbarao JV. Racket sports injuries. In: Sports Medicine and Rehabilitation: A Sports Specific Approach. Buschbacher R, Prahlow N, Dave SJ (eds), Lippincott Williams & Wilkins, Philadelphia 2008. Copyright © 2008 Lippincott Williams & Wilkins.
Aircast/ProCare Brand. Copyright © 2008 DJO Incorporated. All rights reserved.

Most cases no underlying cause
Activity involving overuse of wrist extensor or supinator muscles
Besides tennis- typing, piano, manual work
Most commonly affected muscle is extensor carpi radialis brevis
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