Heath & Beauty - Free Fitness Library
Elbow joint injuries
BY WENDY GREEN MSCP SRP
Clear blue skies, warm breeze, strawberries and cream, Pimms, and of
course tennis! Thoughts of a perfect summers day in England. Tennis
is a very popular racket sport, being played at all levels and abilities
and has a great social tradition with many excellent clubs functioning
nationally. As tennis involves repetitive asymmetrical movements there
is a risk of overuse injuries even in the most conditioned bodies. Technique
and good racket choice play an important role in keeping your body healthy.
The focus will be on the two most common injuries in the upper limb:
TENNIS ELBOW, SHOULDER IMPINGEMENT.
As with any sport adequate warm up and stretching of all major muscles
groups is essential to reduce the risk of sudden muscle tears and strains.
Cool down stretch keeps you functioning for that next match the following
day.
The elbow joint is a common area of injury in many racquet and throwing sports. It forms the link between the multi directional shoulder joint, and the hand, adding extra mobility to the hand in space. The muscles surrounding the forearm and elbow act as stabilisers to the hand to allow many every day actions to take place, i.e.;- eating, pushing, pulling, turning.
The muscles which act over the wrist joint and fingers also originate from around the elbow joint and it is these which when overused give rise to tennis and golfers elbow. These muscles are the wrist extensors (lift wrist back), and flexors (pull wrist down). Muscles which turn the palm over (supinators) and muscles which turn palm to floor (pronators) also work around the fore arm and elbow joint.
The elbow joint allows the lower arm and hand to flex towards the ace, this combination of movement gives great functional dexterity to the hand and wrist. Smooth pain free movement at the elbow joint is essential for dressing, eating etc. Therefore sound location of bones, muscles and ligaments is very important. The elbow joint is also a prime link in all throwing drills and racquet sports.
TENNIS ELBOW
This was recognised in the early 19th century but is much more common
now due to the increase in leisure activities. All racket sports, golf
and any one sided repetitive movements, carpentry, DIY, needlework etc.
can predispose to tennis elbow. Any movements connected with repeated
extension of the wrist can give rise to this overuse problem.
Pain arises on the outside of the elbow usually 1-2cm below the lateral epicondyle (bony prominence outside of elbow, see diagram), and can radiated down the forearm and often up into the upper arm. The pain is initiated with resisted wrist extension. Simple tasks such as lifting a tea pot can reproduce pain once inflammation has occurred. Other diagnoses must be eliminated in a thorough assessment as a trapped nerve in the neck or degenerative changes in the neck can produce referred pain which mimics tennis elbow pain.
Tennis elbow is a degeneration of the extensor carpi radialis brevis tendon (EBRC, muscle which lifts the wrist), where it attaches to the bone (lateral epicondyle), at the elbow. The poor blood supply in this area combined with excessive use causes degeneration in the tendon. Continued use without rest, can then lead to microscopice tears and scarring in the tendon which is then extremely difficult to cure. The attachment of this extensor tendon is also very small so the force per unit area are very high.
Mechanism of injury:
Gradual onset:
1) New racket
2) Wet heavy balls
3) Faulty backhand
4) Too high frequency of play
5) Hitting late
6) Novice player, too much wrist action
Sudden onset:
Attempting to hit a backhand when out of position. Hitting a ball travelling
at 30mph is equivalent to lifting a weight of 55lb (25kg). This force
should be distributed throughout the shoulder, arm and upper body.
Treatment:
Often complicated, with no one single treatment being totally effective. Control of inflammation is the first step using ice, non-sterodial anti inflammatories, and rest from the offending repetitive movement. Then a progression of strengthening and flexibility exercise i.e. essential for full recovery. Any predisposing factors must also be corrected. Physiotherapy treatment with application of ultrasound, laser therapy and massage also increase the rate of healing and recovery. A Chartered Physiotherapist can provide an excellent progressive rehabilitation programme too. See diagrams for stretching and strengthening exercises. They should be performed within the limits of pain free motion. Isometric strengthening should be progressed to concentric and eccentric when inflammation reduction of inflammation allows.
Bracing is common now particularly with the chronic type of problem. This can be effective as it removes some of the stress from the tendon site. A brace is basically a firm band or clasp which fits snugly below the elbow joint and alters the loading on the wrist extensor muscles, therefore reducing the possibility of further inflammation at the tendon site. They can be purchased in most good sports shops or chemists in the first aid section. Sizing is important to obtain firm fit. Most come in small, medium or large. Your physiotherapist may also be able to order one for you from a medical supplier.
Cortisone injections are often used when oral anti inflammatories have failed to work. This is an injection of a steroidal anti-inflammatory directly into the tendon. It may be painful for 48hrs following but if correctly administered can reduce pain and inflammation in the tendon considerably.
Relief sometimes is only temporary, but do not be tempted to have several injections as this can cause the tendon to break down and maybe even tear. Conservative methods are best tried first.
Prevention: Reduce stress on the elbow!
1) Improve physical conditioning of the arm and shoulder (flexibility
and strength)
2) Check racket: Proper grip size, string tension and weight for you
3) Slowly warm up before playing
4) Correct playing technique
Pointers to watch for in technique:
1) Good foot work so you approach the ball properly
2) Hit at the correct moment
3) Use of shoulder and whole body in the stroke. Follow through with
wrist firm
4) Slower court surfaces reduce the speed of the ball
5) Correct racket
Return to play gradually working through forehand drills before progressing to back hand serves.
STRETCH FOR TENNIS ELBOW
Place top of hand against wall, bending wrist down. Hold for 15 secs
and release. Repeat x3. Stretch several time through the day, before
and after playing.
The above exercises should be performed within the limits of pain-free
movement. If pain occurs stop and see your physiotherapist.
SHOULDER IMPINGEMENT
Repetitive intensive serving can cause trapping (impingement) of the
soft tissues in the shoulder resulting in a painful inflamed area. Preparing
to serve, moving into the last few degrees of full elevation reproduces
sudden pain. This can arise due to muscle imbalances in the shoulder
complex (rotator cuff, scapular thoracic area), sudden increase in serving
volume or power, change in technique or commonly in the older player
due to decreasing circulation in the tendonous structures.
Treatment is essential to reduce inflammation, regain shoulder capsule flexibility and rehabilitate muscle strength.
Once inflammation has reduced work progressively through a gradual return to play: Move through the following skills as pain reduces:
1) Fore-arm flat
2) Fore-arm top spin
3) Fore-arm volley
4) Backhand flat
5) Backhand volley
6) Serving, flat through to top spin
7) Play!
Prepare well for those summer days, select the right racket for you, book up for a couple of professional coaching sessions and this will outbalance those physiotherapy fees. Enjoy the long summer evenings.