Tennis Elbow... or a Marionette Puppet?

Tennis Elbow... or a Marionette Puppet?

Tennis Elbow…or a Marionette Puppet?

90 to 95% of people I see with tennis elbow, didn’t get it from playing tennis.

Tennis elbow has a far more technical name, but what fun is that? I enjoy the slang names society makes up for injuries, as much as the medical toffs abhor it. Skiiers thumb, jumpers knee, golfers elbow…laymen can be so much more logical than scientists (who would say ulnar collateral ligament sprain of the first metacarpo-phalangeal joint, patellar tendinopathy and medial epicondylitis, for the previous three conditions).

I do wonder, though, if we got it a bit wrong with tennis elbow. As excited as I was when I first saw a tennis elbow that actually was from tennis, I often think that names such as clarinet elbow, pruning elbow, or pulling-the-trigger-on-the-cleaning-spray-bottle elbow would have been more suitable, according to my clinical experience with the condition.

Nevertheless, tennis elbow is our habitual moniker, and an identifiable term.

Tennis elbow is a mighty stubborn condition to treat. Try and count how many times you use your hands each day – Hundreds? Thousands? Exactly – the forearm is easy to overload, and difficult to rest. Outsmart and avoid tennis elbow – read on!

Anatomy Made Easy

Our hands have many moving parts. This allows us to do things like thread a needle, do up a button, and perform microsurgery. All of these movements are co-ordinated by a myriad of tendons. The tendons, in turn, are controlled by muscles in our forearm.

Think of a marionette puppet – strings move the puppet around by being attached to a controller up above. Likewise, muscles in our forearm contract, pulling on ‘strings’ (tendons) that run through our forearm and into our hand, making one or more fingers move when we ask them to. Our hands are used to perform such fine and delicate movements, so our fingers must also be fine and delicate in size. There is no room for muscle bulk, which would turn fingers into fat clumsy clubs. As demonstration of humans’ fabulous design, therefore, the bulky muscles are stored up in our forearm, leaving skinny tendons to translate the movements into our hands.

The tendons that are in charge of bringing our wrist back and our fingers open, all merge into a common muscle belly in the forearm, which then attaches to the knobbly bit on the outside of the elbow. This common muscle unit is called the extensor muscle group, due to it’s role extending the wrist and fingers.

If you do any small movement with your hands – even just playing with a pen, you will notice that your wrist is bent backwards slightly. This wrist position puts our fingers in the optimal position to activate, and is a large requirement for normal hand function. It is the extensor muscle group that performs this wrist extension movement.

What goes wrong?

Sometimes we make the extensor muscle group do more than it has built up the capacity to tolerate. If we suddenly do a lot of hand activity that requires wrist extension, the muscle group gets overloaded and ‘something’s gotta give’. That ‘something’ tends to be the point where the extensor muscle group attaches onto the knobbly bone on the outside of the elbow. The irritation of this muscle/bone attachment site is tennis elbow (or lateral epicondylitis, if you must know!)

The cause is often a new activity. In the past, I have had tennis elbow ‘victims’ who

-       had taken on some casual work pruning vines in a vineyard

-       were doing a lot of hammering nails for a home handyman job

-       took up squash

In these situations, it was a case of ‘too much, too soon’ –the extensor muscle group was not given time to build up the strength to cope with the new activity.

Other times, is can simply be the accumulation of load that leads to tennis elbow. This is common in people who do a lot of typing, or play a musical instrument. Over time, the extensor muscle group gets used and used, which causes it to progressively tighten and tighten (without the person even knowing), until one day the muscle is too tight to activate in the normal way, and a niggle begins at that attachment point onto the outside of the elbow. The niggle can build up and up, and put the person in a very painful position. 

Once the tennis elbow has set in, it is very hard to get the balance right between rest, use and recovery exercises. Every hand activity becomes accompanied by a tremendous pain in the elbow area, causing the sufferer to lose grip strength, develop other compensations, and ultimately lose function. This can go on for months and months.

Take Action Before You Break

Stretching is often something that people overlook as part of their lifestyle. Anyone who does have the foresight to stretch may simply perform a few rudimentary hammy or calf stretches after a run. We neglect to consider that daily activities load our muscles too. Our forearm muscles are among our most used muscles every day. Despite this, they are the least commonly stretched, and yet they are some of the easiest stretches to do!

For just a few minutes, 2 or three times a day, the stretches listed can dramatically reduce your risk of tennis elbow.

If you pair these stretches with the ‘10%’ rule of starting any new activity, consider your self tennis elbow proof: Start any new activity with a small session, don’t do it on consecutive days to begin with, and increase load or volume by no more than 10% each time.

Injury Proof Toolkit:

1) Change Your Environment

-       If your computer mouse is too low, bring it up to elbow height, and make sure it glides properly and has room to move

-       Check any equipment you are using with your hand/s:- Do your pruning shears need oiling to decrease resistance of use? Is your trigger spray cleaning bottle too full and heavy? Is the grip on your tennis or squash racquet too big or small? Does your shoddy backhand shot warrant a technique lesson?

2) Change Your Habits

-       If you are starting a new hand based activity from scratch, or increasing an activity you already do, start gradually. As a rule of thumb make your first few sessions about 70-80% of what you think you could maximally do.

-       Increase the activity by no more than 10% volume (time and/or intensity) each time

-       Perform the new or increasing activity on alternate, not consecutive days, at least for the first 4 to 6 weeks

-       If you get an ache in your elbow or forearm, take a few days off, then return to the activity at a decreased intensity, provided this is painfree

3) Add These Exercises

	FOREARM FLEXORS 1. Take one arm out in front of you, palm up 2. Using the other hand, pull the fingers and hand back and down 3. You should feel a stretch in your wrist or forearm 4. Hold for 30 seconds. Repeat twice each arm
	FOREARM EXTENSORS 1. Take one arm out in front of you, palm down 2. Using the other hand, curl the hand and fingers down and in 3. You should feel a stretch over the back of your wrist or forearm 4. Hold for 30 seconds. Repeat twice each arm

Karen Finnin
Musculoskeletal Physiotherapist
karen@physios-online.com