Pain on the outside of the elbow is one of the more common sites for elbow pain. Maximal tenderness is generally felt next to the bony protrusion on the lateral elbow called the (lateral epicondyle).

Tenderness may also be felt at the mid forearm and even radiate to the wrist and fingers, this will be aggravated by extending the wrist while trying to hold or lift an object with a pronated hand (palm down).

Causes

Tennis elbow may occur soon after an unaccustomed action or activity, or more insidiously with repeated gripping actions, even lifting a kettle for a cup of tea.

Although as its name implies, it is a common injury arising from a tennis backhand, other aggravating manual tasks may include cooking, knitting, working with tools, gym-work and using a keyboard for extended periods of time.
Tennis elbow is not a definitive diagnosis and may also be called an extensor Tendinopathy, lateral epicondylitis, lateral epicondylagia.

Tennis Elbow Biomechanics

Tennis elbow can be a chronic and disabling condition that primarily occurs in a recreational athlete.
Research shows that a backhand stroke or an overhead serve may be related to faulty biomechanics in the novice player.
Experienced players hit the ball with extended wrists and keep their wrists extended through the impact. They also keep their forearm muscles concentrically activated to generate racquet speed throughout ball contact.

Novice players more often hold the racquet with wrist flexed, and then hit the ball with wrist further into flexion. The extensor muscles are forced to work eccentrically prior to contracting concentrically.

It has been demonstrated that tennis elbow has been associated with both chronic and acute eccentric contraction of the wrist extensors during a backhand stroke.

When an individual grips a tennis racquet with the finger flexors, there is a duel as extensor muscles are frequently over activated to counter the grip force of the flexors.
A study in clinical biomechanics demonstrated that holding a racquet handle with the wrist in extension could lessen the activity of the extensor muscles during functional gripping.

Chronically overloaded wrist extensor muscles may eventually lead to changes in the common extensor tendon, including muscle neurology as demonstrated by weakness in wrist extensors and overactive finger extensors with delayed reaction times.

Other Sources of Pain:

• Cervical spine
• Thoracic spine
• Referred pain from shoulder muscles
• Elbow joint dysfunction
• Nerve entrapment

Examination

On examination grip force is reduced in combination with wrist extensor weakness, yet there is increased tightness and activation of the long finger extensors.
Pain may also be found on the opposite arm in long standing cases, due to central sensitization.

Assessment

• Passive, active and resisted movements
• Palpation for myofascial trigger points
• Examination of scapular muscles
• Cervical spine
• Thoracic spine
• Neural tension tests

Treatment and Management

The initial treatment is focused on pain reduction and optimization of movement.

Modification of activity and education as to the initial cause   of pain, such as load management, manual handling, racket grip, or technique modification.

Manual therapy of specific muscles and articulations.

Dry needling

Soft tissue techniques

Exercise for strength and coordination.