Is ‘Tennis Elbow’ Getting On Your Nerves?

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10% of people suffering with elbow pain, diagnosed as Tennis Elbow, were found to have co-existing nerve compression. (Brotzman & Wilk, 2007)

Thought Of The Day…

“Live not as though there were a thousand years ahead of you. Fate is at your elbow; make yourself good while life and power are still yours.”

– Marcus Aurelius quotes (Roman emperor, best known for his Meditations on Stoic philosophy, AD 121-180)

Tennis Elbow (Medial Epicondylitis)

Anatomy of a tennis elbow
Anatomy of a tennis elbow

An overuse injury of the tendon(s) of particular forearm muscles on the outer part of the elbow. Overuse, usually from gripping-type activity, causes micro-tears (tendinosis), leading to pain and function loss. (The diagnosis of Tennis Elbow by itself excludes the presence of nerve compression).

Common Signs Of Tennis Elbow

  • Gradual onset of symptoms
  • Pain over the outer part of elbow
  • Pain caused by gripping/wringing/twisting actions
  • Rest eases the pain
  • 30-55 year olds most affected
  • 95% of cases in non-tennis players
  • Poor technique: any activity involving gripping/wringing/twisting action
  • Equipment fault: e.g. racquet grip size, string tension

Nerve Compression

The Radial Nerve passes around the outer part of the elbow. Compression commonly takes place at 4 sites along this path. This can be due to muscular tightness, bone/ligament scarring, damage or a combination of the above, and can co-exist with Tennis Elbow. This can ‘complicate’ the picture, as the symptoms often mimic Tennis Elbow, making diagnosis more difficult. If nerve compression is present, recovery will likely take longer.

Some additional signs and symptoms may be present with Radial Nerve compression. These include:

The type of pain mimics Tennis elbow – but worse with rotation activity of the wrist.

  • Pain at rest
  • Can have paraesthesia in the hand and lateral forearm.
  • Pain over mid-upper humerus.
  • Pain resisting turning the palm upwards (elbow at 90 deg).
  • Positive nerve conduction study

Treatment For Nerve Compression

  • Activity modification: stop/reduce gripping and repetitive activities that are painful. Lifting should be done with palms facing upwards whenever possible.
  • Correction of bio-mechanics: Correction of technique if required. Correcting ergonomics of e.g. workstation.
  • Anti-Inflammatories (NSAIDS): Brotzman and Wilk (2007), suggest use of Celebrex or Ibruprofen, but only in acute phase to reduce inflammation.
  • Icing: 10-15 mins 4-6 x daily in acute phase.
  • Stretching: If the compression is due to muscular tightness, stretching the affected muscles is important.
  • Physiotherapist: your physiotherapist will establish what is the cause of your symptoms, and will provide appropriate treatment. This may include joint mobilization, scar management, nerve mobility exercises, postural education, and myofascial release.

Additional Information

There are of course other causes of elbow pain. Below is a table of the 4 most common causes of elbow pain, and their defining symptoms

 Type/SitePhysiotherapyTestNeurological Signs
Tennis ElbowWell localised painMills, Crozen, MaudsleyNone
Joint painGeneralised elbow painCompression through jointNone
Referred from the neckDiffuse outer arm pain, neck pain/stiffnessReduced neck ROM, Spurlings test +veMay be abnormal, Neural tension
Radial NerveVague, diffuse forearm ache. Pain at restResisted long-finger ext, forearm supination Paresthesia in the first web space (5-10% of pt’s)

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Brotzman, S., & Wilk, K. 2007 Handbook of Orthopaedic Rehabiliitation. Mosby, USA.

Brukner, p., & Khan K. (200..) Clinical Sports Medicine