CHAPTER 91 • TENNIS 535- Pain with exercise activity that alters the exercise.
- Pain caused by heavy activities of daily living.
- Pain caused by light activities of daily living.
- Intermittent pain at rest that does not disturb sleep.
- Constant rest pain (dull aching) and pain that dis-
turbs sleep.
- Pain location is specific:In lateral elbow tendinosis,
the pain is localized just distal and anteromedial to the
lateral epicondyle and along the proximal extensor
aspect of the forearm. In medial elbow tendinosis, the
pain is focused from the tip of the medial epicondyle
and distally 2 to 3 in. down the track of the common
flexor origin. In the stroke mechanics of tennis, lateral
elbow pain is usually associated with the back hand
while medial elbow pain is commonly associated with
the forehand and serve. - Rotator cuff tendinosis also has the pain phase
sequence noted for the elbow (see pain phases). Pain
is characteristically noted in the anterior shoulder
with overhead activities and compression forces such
as rolling onto the shoulder during sleep. Full motion
is commonly restricted and weakness is common
(especially external rotation and abduction). In tennis,
shoulder pain is commonly present in the serve, over-
head and high backhand follow through.
CLINICAL EXAMINATION
- Lateral elbow: The quintessential sign is focused
tenderness over the extensor carpi radialis brevis
(ECRB) just distal and anteromedial to the lateral epi-
condyle. Pain in the same area is noted with resisted
wrist extension or hand shaking. Stability and motion
are usually normal. - Medial elbow:The classical sign is tenderness at the
tip of the medial epicondyle and distal along the track
of the flexor carpi radialis and pronator teres.
Provocation pains with resisted wrist flexion and fore-
arm pronation are the norm. A positive Tinel’s sign
indicative of ulnar nerve sensitivity is often present at
the medial epicondylar groove. Motion and stability are
usually normal but extension is occasionally restricted.
Valgus instability can occur in the uncommon instance
of associated medial collateral ligament injury. - Shoulder (rotator cuff):Tenderness is located over
the greater tuberosity. If associated acromioclavicular
(AC) osteoarthritis is present, tenderness will also be
noted over the AC joint. Forced forward flexion
(impingement sign) elicits pain. Motion may or may
not be restricted. Weakness—especially external
rotation and abduction—are characteristically pres-
ent as the specific demands of tennis typically
weaken the external rotators and scapular stabilizers.
Crepitus with shoulder abduction is often present in
the coracoacromial arch. Instability may be noted but
is more likely noted in swimmers and baseball pitch-
ers, rather than tennis players.DIFFERENTIAL DIAGNOSIS- Lateral elbow:Rarely posterior interosseous nerve
entrapment may masquerade as tendinosis. The symp-
toms are more distal and pain may be elicited with
resisted supination. Intra-articular synovitis and lat-
eral plica may occur in combination with tendinosis.
Cervical radiculopathy (C7 root) has been known as
well to have referred pain at the lateral elbow.
TREATMENT- The basic treatment of tennis related overuse injuries
of the rotator cuff and elbow tendons are improvement
of the shoulder and arm and diminution of abusive
activity. The biological goals of tissue enhancement
are neurovascularization and fibroblastic infiltration
with collagen production, thereby altering the devital-
ized degenerative tendinosis tissue in a positive
manner (e.g., cure). The mechanism to accomplish
cure is rehabilitative exercise. - Pain control:Pain control may take several forms. It
should be noted that pain control does not indicate cure
(e.g., neovascularization; fibroblastic proliferation; col-
lagen production; and the restoration of strength,
endurance, and flexibility). The concept of pain control
is to free the patient from pain inhibition so the curative
process of rehabilitative exercise can proceed effec-
tively. The proven approaches to pain control include
relative rest and medication (analgesic and anti-inflam-
matories, both nonsteroidal, and cortisone). Cortisone
may be delivered by direct injection, iontophoresis, or
orally. The modalities of physical therapy including
heat, cold, massage, electrical stimulation, and ultra-
sound can also be helpful. Recently shockwave therapy
has been advanced as a modality of pain control and
possibly a cure but evidence is unconvincing at this
time. Alternative methods, such as magnets and copper
bracelets, have no scientific evidence of effectiveness.
Acupuncture has some evidence of temporary pain
control but no evidence of biological cure. - Rehabilitation:Resistance exercise is the key com-
ponent. An effective program includes varying and
properly sequenced resistances including isometrics,
isotonics, isokinetics, and isoflex (tension cord). - The cardinal six-exercise arcs for tennis elbow include
wrist flexion, wrist extension, pronation, supination,
and radial and ulnar deviation. Since the upper arm,
shoulder, and upper back are characteristically weak in