REVIEW ARTICLE

Year : 2015 | Volume : 15 | Issue : 1 | Page : 13-19

Therapeutic management of tennis elbow

Fozia Bashir, Shibili Nuhmani

Department of Rehabilitation Sciences, Jamia Hamdard, New Delhi, India

Date of Web 19-Jan-

Publication 2015

Correspondence Address:
Shibili Nuhmani
Department of Rehabilitation Sciences, Jamia Hamdard, New Delhi
India

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DOI: 10.4103/1319-6308.149522

Abstract

Patients with conditions like tennis elbow are frequently referred to

physiotherapy. Patients with this condition suffer from pain and tenderness
over lateral epicondyle, which hampers their activities of daily living.
Lateral epicondylitis (tennis elbow) is the most frequent type of
myotendinosis and can be responsible for substantial pain and loss of
function of the affected limb. Muscular biomechanics characteristics and
equipment are important in preventing the conditions. This article presents
on overview of the current knowledge on lateral epicondylitis and focuses
on, conservative treatment and recent surgical techniques are outlined.
This information should assist health care practitioners to manage
symptoms, improve activity and reduce relapse who treat patients with this
disorder.
 Abstract in Arabic

‫التنس‬ ‫لمرفق‬ ‫العالجية‬ ‫االجراءات‬:

.‫المرضى الذين يعانون حاالت مرضية مثل مرفق التنس كثيرا ما يحالون ألقسام العالج الطبيعي‬
‫ ويع ّد‬.‫والمرضى من هذا النوع يعانون آالما ً ورقة على اللقميمة الوحشي األمر الذي يعوق نشاطهم اليومي‬
‫ وتعد الخصائص‬.‫التهاب مرفق التنس المسئول عن اآلالم األساسية و فقدان العضو المصاب لوظيفته‬
‫ هذه المقالة تقدم نظرة عامة عن التهاب‬.‫الحيوية للعضالت و المعدات عوامل مهمة للوقاية من المرض‬
‫ هذه المعلومات يمكن أن‬.‫مرفق التنس و تركز على العالج التحفظي والتقنيات الحديثة للعالج الجراحي‬
‫تفيد العاملين في حقل الرعاية الصحية لمعاجة ااألعراض و تحسين النشاط و تقليل حاالت االنتكاس‬.

Keywords: Extensor muscles, lateral elbow pain, myofascial trigger

points

How to cite this article:

Bashir F, Nuhmani S. Therapeutic management of tennis elbow. Saudi J
Sports Med 2015;15:13-9

How to cite this URL:

Bashir F, Nuhmani S. Therapeutic management of tennis elbow. Saudi J
Sports Med [serial online] 2015 [cited 2019 Feb 16];15:13-9. Available
from: http://www.sjosm.org/text.asp?2015/15/1/13/149522

Introduction

Tennis elbow has many analogous terms, including lateral elbow pain,
lateral epicondylitis, rowing elbow, tendonitis of the common extensor
origin (CEO), and peritendonitis of the elbow. Tennis elbow is
characterized by pain and tenderness over the lateral epicondyle (LE) of
the humerus and pain on resisted dorsi-flexion of the wrist, middle finger,
or both. [1] For the purposes of this review, tennis elbow was restricted to
lateral elbow pain or lateral epicondylitis. Tennis elbow is a painful
condition affecting the tendinous tissue of origins of wrist extensor
muscles at the LE of the humerus, leading to loss of function of the
affected limb. It can have a major impact on patient's social and
professional life. [2]

Research into the etiology of tennis elbow has revealed that it is primarily
an overuse injury that results in micro tears of the hyaline region of the
extensor muscles that attach on the lateral side of the forearm. However,
pain localized on the medial side of the elbow is also possible. The actual
diagnosis of tennis elbow is often incorrect because it is termed tendonitis.
This expression has been disputed by elbow injury experts, who note that
tendonitis implies inflammation of the affected region. The most common
form of tennis elbow (LE tendinosis) is a painful condition that rarely
presents with any inflammation. This terminology echoes the belief that
this injury is degenerative rather than acute.

One of the common problems with tennis elbow is incorrect diagnosis.

This occurs because at least 43 different pathologies of the elbow joint
have been documented. Because the pathology of the injury is seen
primarily at the microscopic level, it is relatively easy to misclassify tennis
elbow in the intact human arm as bursitis, arthritis, or one of many other
ailments. [3]

Epidemiology

According to the observational study, the prevalence of lateral

epicondylitis is 1.3%, and medial epicondylitis is 0.4%. The incidence may
approach 1-3% in the general population while the incidence in general
practice is approximately 0.4-0.7%. Lateral epicondylitis is equally
common among men and women, occurs more frequently among whites
and in dominant arm and increases with age, peaking between ages 30
and 50 with a mean age 42. It seems to occur equally among blue-collar
and white-collar workers and between socioeconomic classes. [4] The
natural course of the condition seems to be favorable with spontaneous
recovery within 1-2 years in 80-90% of the patients.

Anatomy

The human elbow is the summation of three articulations. The first 2 are
the ones traditionally thought of as constituting the elbow: The
humeroulnar articulation (the synovial hinge joint with articulation between
the trochlea of the humeral condyle and the trochlear notch of the ulna)
and the humeroradial articulation (the articulation between the capitulum
of the humeral condyle and the concavity on the superior aspect of the
head of the radius). The third is a pivot-type synovial joint with articulation
between the head of the radius and the radial notch of the ulna. These 3
articulations, forming two different aspects, allow flexion and extension of
the elbow, as well as supination and pronation of the forearm and wrist at
the elbow. When the elbow is in anatomic position, the long axis of the
forearm typically has an offset (lateral inclination or valgus at the elbow) of
about 19° from the long axis of the humerus. [5] This angle shows no
difference between genders but does increase slightly with age into
adulthood.
 Causes of tennis elbow

Any activity that involves repetitive twisting of the wrist can trigger tennis
elbow. This includes tennis and other racquet sports, swimming, golfing,
turning the key, or using a screwdriver, hammer, or computer. The tendon
is the part of a muscle that attaches to the bone. Forearm muscles attach
to the outer bone of the elbow. Researchers are finding that tennis elbow
often occurs when a specific muscle in the forearm - the extensor carpi
radialis brevis (ECRB) muscle - is damaged. The ECRB helps stabilize the
wrist when the elbow is straight. [6] Repetitive stress weakens the ECRB
muscle, causing microscopic tears in the muscle's tendon at the point
where it attaches to the outside of the elbow. These tears produce
inflammation and pain. Based on clinical studies, other factors suggested
as contributing to the occurrence of tennis elbow are playing experience,
ability and racket type. Inexperienced players more often use improper
stroke techniques and are more prone to mishit the ball that results in
greater mechanical stress on the elbow joint. Heavier, stiffer or more
tightly string rackets increase the muscle stress required during swing and
impact. Colt reported that metal rackets were a cause of tennis elbow
because they allow shock waves to pass unimpeded. [7]

Signs and symptoms

Symptoms of the condition generally include tenderness over the anterior

aspects of the epicondyle of the humerus. Pain in extensor muscles of the
forearm induced by gripping or resistive movements in the wrist and
localized pain in the olecranon region induced by carrying weight. The
pain ranges from an occasional throbbing to severe agony although
passive movements are generally pained free.[8]

Proper stroke biomechanics in tennis players

Tennis elbow is thought to result from overuse of ECRB muscle by

repetitive micro trauma resulting in a primary tendinosis of ECRB with or
without involvement of extensor digitiform communis. In tennis, the
predominant activity of wrist extensors in all strokes (serve, forehand, one
or two-handed backhand) might be one explanation for predisposition to
the condition. It is generally believed that tennis players using a two-
handed backhand hardly develop tennis elbow as the nondominant arm
appears to absorb more energy, which changes swing. Electromyography
(EMG) showed reduced amplitude in extensor muscle during a two-
handed backstroke. The higher occurrence of tennis elbow among
recreational tennis players compared with experienced players has been
shown to be due to the ability of experienced players to reduce impact
transmission from racquet to the wrist and elbow. EMG studies showed a
significant difference between both groups.

Tennis players should be instructed to release their grip tightness quickly

after the ball to racquet impact in order to reduce impact transmission to
wrist and elbow. Aberrant techniques should be identified and corrected.
The forehand stroke should allow the players to hit the back in front of the
body with the wrist and elbow extended. This allows the torso and upper
arm to provide the majority of power and reduce stress on wrist extensors.
The two-handed backward stroke allows a distribution of force between
upper extremities and also diminishes the force on LE. Proper equipment
is also essential in preventing tennis elbow. According to Nirschl, the
proper grip size is assessed by measuring from the proximal palmar
crease to tip of finger along its radial border, currently most tennis players
use a racquet grip size 2-3 (size 1 for children). Lighter racquets are easier
to maneuver but provide less momentum for impact. Using racquets with
less string tension or with a higher string count per unit area and playing
on slower surfaces such as clay courts, will diminish the loads transmitted
to the elbow. [9] The wrist kinematics and EMG data show that novice
players eccentrically contract their wrist extensors muscles through the
stroke that could contribute to tennis elbow. [10]

Research published in the American Journal of Sports Medicine claims

that your tennis swing technique, not the racket grip size, may be the main
cause of tennis elbow (lateral epicondylitis). In the past, many sports
medicine physicians would recommend players with a tennis elbow switch
to a different size racket grip to treat and prevent these injuries. This new
study finds no correlation between grip size and incidence of overuse
injuries.

The study authors indicate that grip size changes the impact forces, but
that is unlikely to contribute to overuse injuries and tendonitis. They go on
to recommend that players use the grip size they find most comfortable.
The study followed 10 male and six female NCAA tennis players-none of
whom had any history of elbow problems. The players then performed
one-hand backhand strokes using identical tennis rackets with three
different grip sizes. Researchers then measured the firing patterns of
forearm muscles during the swings. They found no difference in the firing
patterns of the muscles with different grip sizes. The findings further
support previous research that finds improper form is one of the biggest
causes of tennis elbow. This reinforces the recommendation that players
with elbow pain work more on their tennis swing mechanics and stroke
instead of changing equipment. [11]
 Treatment

Rest is the first line of defense against this condition, because the tennis
elbow is an overuse injury, the first practical action would be to stop
playing tennis until the pain is gone. Anything, within reason, that causes
the pain to become stronger or more intense, should be avoided.
Continuing to play the sport or other activity that caused the injury, will
only make the problem worse. [12]

Icing

Icing will work only if the condition is inflammatory, cases dominated by

muscle dysfunction will not respond, especially well to ice. Ice is
recommended for its local vasoconstrictive and analgesic effect. Experts
recommend it to do it every 20-30 min every 3 hourly or 2-3 days or until
the pain is gone. [13]

Therapeutic ultrasound

Ultrasound has been widely used and accepted adjunct modality for the
management of many musculoskeletal conditions. It was introduced as
therapeutic modality in 1950s. In late 1960s and 1970s, reports on the
nonthermal therapeutic effects of US, primarily in the area of enhanced
tissue healing further bolstered its popularity, According to survey of
orthopedic certified specialist, the most common use is for where to
decrease soft-tissue inflammation, increase tissue extensibility, enhance
scar tissue remodeling, increase soft-tissue healing, decrease pain and
decrease soft tissue swelling. Other uses were to deliver medication for
soft-tissue inflammation, pain management and soft-tissue swelling. [14]

Eccentric exercise

Therapeutic eccentric exercise (TEE) has been found to be an effective

intervention for a variety of tendinopathy including Achilles tendinosis,
shoulder impingement, and patellar tendinopathy. One of the first
recommendations in the literature regarding the use of eccentric exercise
for managing tedinopathies was made by Stanish et al. in 1986. They
suggested that the eccentric exercise effectively "lengthened" the muscle-
tendon complex resulting in structural remodeling of the tendon with
hypertrophy and increased tensile strength of the tendon. [15]

Eccentric exercise may also provide neuromuscular benefits through

central adaptation of both agonist and antagonist muscles; therefore, TEE
may provide both a structural and functional benefit during tendinopathy
rehabilitation. Interestingly, some patients with LE exhibit lowered pain
pressure thresholds (PPT) and larger referred pain patterns than would
occur solely due to the presence of trigger points, suggesting a central
nervous system mediation of pain. Many questions remain as to the
mechanism of the effectiveness of TEE, as well as the appropriate
dosage. In a recent systematic review, Woodley et al. noted a lack of high-
quality studies comparing the effectiveness of eccentric exercise to
standard management of tendinopathies. [16]

Historically, a popular choice for treating tendonitis was deep friction

massages. However, as evidenced by the 2002 Cochrane review, there is
simply not a large enough sample size to draw any conclusions in regards
to control of pain or improvement in function. The concepts of cross-friction
techniques have since evolved into an augmented soft-tissue mobilization,
more commonly known as the "Graston Technique Instrument-Assisted
Soft Tissue Mobilization" or simply Graston. The Graston protocol for
epicondylosis uses specifically designed stainless steel instruments, which
are moved with multidirectional strokes around the bony prominence of the
elbow. Preliminary studies utilizing this Graston technique have shown
promising results when compared to a traditional physiotherapy protocol in
the treatment of lateral epicondylitis.

Perhaps the most popular of soft tissue techniques to gain recent notoriety
is Active Release Technique. This therapy is based on the observation
that the anatomy of the forearm has been traversing tissues situated at
oblique angles to one another that is prone to reactive changes producing
adhesions, fibrosis and local edema and thus pain and tenderness. During
active release therapy, the clinician applies a combination of deep digital
tension at the area of tenderness and the patient actively moves the tissue
through the adhesion site from a shortened to a lengthened
position. [17] For example, in order to treat ECRB. The clinician applies
proximal tension distal to the LE while the patient extends the elbow and
pronates and flexes the wrist. A preliminary report on the use of ART ® for
a variety of upper extremity overuse syndromes found a 71% efficacy rate.

Muscle-strengthening program

The muscle-strengthening program was initially proposed by Dr. Ernest W.

Johnson (oral communication, October 2003), an American physiatrist
from Ohio State University in Columbus. The program encompasses a 10
repetition maximum of eccentric and concentric movements of the wrist
extensor muscles in two different positions: First with the elbow flexed to
90°, then with the elbow extended to 180° The forearm is pronated in both
positions. Slow full-wrist extensions are followed by slow full-wrist flexions;
each full-wrist extension and full-wrist flexion should take 5-10 s. A "10
repetition maximum" means that it is difficult (or impossible) to do more
than 10 repetitions with a given weight (handheld dumbbell). It is normal
for pain to be present while performing the exercises. The weight is
progressively increased when 10 repetitions can be completed without
pain. [18]
Cyriax physical therapy

cyriax and cyriax claimed substantial success in treating tennis elbow

using deep transverse friction in combination with mills manipulation that is
performed immediately after deep transverse friction. Patient must follow
protocol 3 times a week for 4 weeks. Deep transverse friction is performed
only at the exact site of the lesion with the depth of friction tolerable to the
patient. It produces vasodilatation and increases blood flow to the area. [12]

Trigger point release: In a study, two groups were taken blindly and were
examined for the presence of myofascial trigger points (TrPs).The quality
and location of the evoked referred pain and PPT at the LE on right upper
extremity were recorded. Several lateral elbow parameters were also
evaluated. Result suggested that in patients with LE the evoked referral
pain and its sensory characteristics shared similar patterns as their
habitual elbow and forearm pain, consistent with active TrPs. Lower PPT
and larger referred pain pattern suggest that peripheral and central
sensitization exist in LE. [19]

In 1999, David Simons, M.D, discovered that a trigger point is a

dysfunction that occurs at the point where a nerve enters a muscle, trigger
points result in muscle, which had been traumatized by accidents, sports,
occupational stress and overuse. It can remain for life unless treated.
When pressure is applied to trigger points, the chemical/pressure cycle is
interrupted, which helps to stop the contraction and pain in muscle.

Elbow strapping

Biomechanical data on most bracing and protective equipment systems is

lacking. To better understand the clinical success of counter force bracing,
a biome chemical analysis of braced and unbraced tennis players (serve
and backhand strokes) was undertaken. Three-dimensional
cinematography and electromyographic techniques were used. Three
commonly used counter force braces (lateral elbow, medial elbow, and
radial ulnar wrist) were compared with the unbraced condition. The overall
results basically reveal positive bio mechanical alterations in forearm
muscle activity and angular joint acceleration dependent upon the brace,
and joint area analysed. [20]Jafarian et al. compared 3 common types of
orthoses for their effect on grip strength in patients with lateral
epicondylosis. In a randomized, controlled study of 52 patients, maximum
and pain-free grip strength were assessed with the patient wearing an
elbow strap orthosis, an elbow sleeve orthosis, a wrist splint, or a placebo
orthosis. Use of the elbow strap and sleeve orthoses resulted in an
immediate and equivalent increase in pain-free grip strength;
consequently, the researchers suggest that either of these types of
orthosis may be used. The wrist splint provided no immediate
improvement in either pain-free or maximum grip strength. [21]
A study in 2008 by "Altan" and "Kanrtn" compared treating 50 individuals
with symptoms of lateral epicondylitis for <12 months with either a typical
counter force forearm brace versus treatment with 10-15° dorsi-flexion
wrist splint. Parameters of pain at rest and with wrist extension sensitivity,
hand grip strength and subjective response to treatment were measured at
baseline 2 weeks and 6 weeks. No formal physical therapy (PT) or home
exercise program was recommended. The counter force brace group
demonstrated a significant reduction in pain at rest and during movement
at 2 weeks while sensitivity and grip strength was not changed at 2 weeks.
At 6 weeks, significant improvement was noted in all parameters with
implementation of counter force bracing [12] Elbow strapping is done to
protect the injured tendon from further strain. Ergonomic measures are
often initially recommended.

Wrist manipulation

Preliminary evidence exists for use of scaphoid thrust manipulation

techniques in the treatment of lateral epicondylitis. In a pilot, study Strujis
et al., randomly assigned 31 patients with lateral epicondylitis to receive
either scaphoid thrust manipulation or a multimodal treatment approach
consisting of ultrasound, friction massage and strengthening exercise. All
patients underwent treatment over 6-week period. [22] At termination of PT,
the group receiving scaphoid manipulation exhibited significantly less pain
during day measured by visual analog scale.

Mulligan's mobilization with movement

Mulligan's mobilization with movement (MWM) is a nonthrust manipulative

technique. Vicenzino and wright initially investigated the effects of a
course of MWM treatments on the outcome of pain and function in a
patient with lateral epicondylitis using a single-subject design and the
results were encouraging, resulted in rapid reduction in pain and improved
function that followed. [23] In a pilot study, collagen-producing cells derived
from skin fibroblasts were used for treatment of refractory lateral
epicondylitis (CEO tendinosis) was done on twelve patients (five men and
seven women; mean age 39.1 years) with clinical diagnosis of refractory
lateral epicondylitis. Laboratory-prepared collagen-producing cells derived
from dermal fibroblasts were injected into the sites of intra-substance tears
and fibrillar discontinuity of the CEO under ultrasound guidance. The
outcome assessment was done over 6 months using (i) Patient-Rated
Tennis Elbow Evaluation scale for pain severity and functional disability
and (ii) The tendon healing response was measured using four criteria on
ultrasound - tendon thickness, hypo echogenicity, intra-substance tears
and neovascularity.

Successful preparation of cell cultures rich in collagen-producing cells was

possible in the laboratory. After injection, the median PRTEE score
decreased from 78 preprocedure status to 47 at 6 weeks, 35 at 3 months
and 12 at 6 months (P < 0.05). The healing response on ultrasound
showed the median decrease in - (a) number of tears from 5 to 2, (b)
number of new vessels from 3 to 1 and (c) tendon thickness from 4.35 to
4.2 (P < 0.05). Eleven of the 12 patients had a satisfactory outcome such
that only one patient proceeded to surgery following failure of treatment at
the end of 3 months. Our pilot study suggests that these collagen-
producing cells can be injected safely and may have therapeutic value in
patient's suffering from refractory CEO tendinosis. [24]

Low-level laser

Low-level laser therapy (LLLT) five systematic reviews were identified. The
most recent (which covered tendinopathy generally) 27 utilized laser dose
standards defined by the World Association for Laser Therapy (WALT) to
assess the adequacy of treatment within included studies. 28 Twelve (from
25) included studies showed positive outcomes in the short-term. In a
previous review specific to LLLT for LE, 29 13 trials (n = 730 patients)
showed reductions in pain and increased grip strength (comparably,
corticosteroid injections show a more rapid onset in pain reduction and a
larger effect size in the same period). A subgroup analysis showed these
effects were associated with narrowly defined doses of 904 nm
wavelength LLLT (the treatment procedure is described as direct
irradiation of approximately 5 cm2 of the tendon insertion at the lateral
elbow, with a dose of 0.25-1.2 J, and mean output 5-50 mW. WALT also
recommended peak pulse output. One Watt, and power density of <100
mW/cm 2 30) and an added value effect of combining LLLT with exercise
therapy. The authors suggest these positive findings are in spite of a
negative publication bias across a relevant LLLT literature. Only 2 studies
present results for medium-term outcomes of LLT that show positive
effects observed up to 24 weeks. 29 Although no adverse responses were
reported for LLLT in either systematic review, this treatment may not be
universally available therapy. [25] A recent study done by Bhatt et al.
suggests that weakness of the shoulder region especially rotator cuff and
scapular musculature is responsible for lateral epicondyalgia. In this study
strengthening of lower and middle trapezius muscle for 10-week period
has shown good results, and the grip strength has improved in patients
with lateral epicondylgia. [26]

Topical nitrates

Animal studies suggest that the nitric oxide stimulate collagen synthesis by
wound fibroblasts and therefore, may play a role in healing extensor
tendons. One randomized controlled trial (RCT) suggests that topical
nitrate patches may be effective in patients with lateral epicondylitis, but
confirmatory studies are needed. The RCT of 86 patients compared a
nitroglycerin transdermal patch with a placebo patch. The nitroglycerin
patch reduced elbow pain with activity at 2 weeks, reduced epicondylar
tenderness at 6 and 12 weeks, and increased wrist extensor mean peak
force and total work at 24 weeks. At 6 months, 81% of treated patients
were asymptomatic during activities of daily living. [27] Many physicians are
skeptical about using corticosteroid injection to manage treatment for
workers and other patients suffering from LE tendinopathy (tennis elbow).
These doubts are well founded, based on compelling evidence regarding
the long-term outcomes for tennis elbow sufferers who are being treated
with corticosteroids.

Manual therapy versus injections: In February 2013 the results of a clinical

trial by Coombes and colleagues entitled, "Effect of corticosteroid injection,
physiotherapy, or both on clinical outcomes in patients with unilateral
lateral epicondylalgia: A RCT," were published in the Journal of the
American Medical Association. In this trial, 43 patients with chronic
tendinopathy randomly received corticosteroid injection, 41 received
placebo injection, 40 received corticosteroid injection plus physiotherapy,
and 41 received placebo injection plus physiotherapy. Patients receiving
corticosteroid injection - with or without physiotherapy treatment - were
found to have a greater rate of recurrence of their condition at 1-year (54%
versus 12% in the placebo injection group).

The key finding of the study was that although corticosteroids reduced
pain for these patients as early as 4 weeks, they were 4-5 times more
likely to be worse off in the long run. By contrast, the group that received
placebo injections combined with physiotherapy experienced a substantial
improvement in pain after 4 weeks, with no worsening in the rate of
recurrence, compared with those receiving the placebo injection alone. In
this clinical trial, physiotherapy treatment consisted of the previously
described combination of specific exercises and manual therapy. Despite
the research findings, it may not be sufficient to reassure patients with LE
tendinopathy that their condition is usually self-limiting within 8-12 months,
and that ongoing symptoms do not necessarily signify ongoing tissue
damage. Most patients would prefer to receive a list of treatment options
that will hasten their recovery without increasing the risk of recurrence. [28]

Summary

There is no true consensus on the most efficacious management of lateral

epicondylitis, especially for long-term outcomes. Furthermore, most
studies do not differentiate between clinical and statistical significant
effects. Although, corticosteroid injections do show large effects in pain
reduction. This is seen in short-term and treatment is associated with risk
of adverse events in long-term reoccurrence. If available LLLT may be a
safe alternative choice for beneficial but smaller short-term effects,
especially if considered as an adjunct to exercise therapy. Combined
physiotherapy treatment packages have been shown to give relief in
medium-term, but effects are only slightly better than advice and a wait
and see approach in long-term. There is very limited evidence to support
injections of blood plasma, botulinum toxin in refractory lateral
epicondylitis. Advice with a wait and approach are recommended as first-
line treatment in primary cases for most cases. [29]
 Acknowledgments

We express our sincere thanks to Dr. Zoheb A. Siddiqui and Dr. Nayeem
U. Zia for helping in the review process.

References

1. Assendelft W, Green S, Buchbinder R, Struijs P, Smidt N. Tennis

elbow. BMJ 2003;327:329.

2. Garg A, Hegmann KT, Wertsch JJ, Kapellusch J, Thiese MS, Bloswick

D, et al. The WISTAH hand study: A prospective cohort study of distal
upper extremity musculoskeletal disorders. BMC Musculoskelet Disord
2012;13:90.

3. Nuhmani S, Akthar N. Biomechanics and common injuries in

professional tennis. J Sci 2014;4:60-3.

4. Waseem M, Nuhmani S, Ram CS, Sachin Y. Lateral epicondylitis: A

review of the literature. J Back Musculoskelet Rehabil 2012;25:131-
42.

5. Kraushaar BS, Nirschl RP. Tendinosis of the elbow (tennis elbow).

Clinical features and findings of histological, immunohistochemical,
and electron microscopy studies. J Bone Joint Surg Am 1999;81:259-
78.

6. Bunata RE, Brown DS, Capelo R. Anatomic factors related to the

cause of tennis elbow. J Bone Joint Surg Am 2007;89:1955-63.

7. Gruchow HW, Pelletier D. An epidemiologic study of tennis elbow.

Incidence, recurrence, and effectiveness of prevention strategies. Am
J Sports Med 1979;7:234-8. [PUBMED]

8. Verhaar JA. Tennis elbow. Anatomical, epidemiological and

therapeutic aspects. Int Orthop 1994;18:263-7.

9. De Smedt T, de Jong A, Van Leemput W, Lieven D, Van Glabbeek F.

Lateral epicondylitis in tennis: Update on aetiology, biomechanics and
treatment. Br J Sports Med 2007;41:816-9.

10. Blackwell JR, Cole KJ. Wrist kinematics differ in expert and novice
tennis players performing the backhand stroke: Implications for tennis
elbow. J Biomech 1994;27:509-16.

11. Bernhang AM, Dehner W, Fogarty C. Tennis elbow: A biomechanical

 approach. J Sports Med 1974;2:235-60. [PUBMED]
12. Stasinopoulos D, Johnson MI. Cyriax physiotherapy for tennis
elbow/lateral epicondylitis. Br J Sports Med 2004;38:675-7.

13. Jobe FW, Ciccotti MG. Lateral and medial epicondylitis of the elbow. J
Am Acad Orthop Surg 1994;2:1-8.

14. Kachanathu SJ, Mallyan D, Nuhmani S, Vellapallil S. Pulsed versus

continuous ultrasound therapy: As a management of lateral
epicondylitis. Innov J Med Health Sci 2013;3:242-5.

15. Stanish WD, Rubinovich RM, Curwin S. Eccentric exercise in chronic

tendinitis. Clin Orthop Relat Res 1986;208:65-8.[PUBMED]

16. Woodley BL, Richard J Newsham-West, Baxter GD. Chronic

tendinopathy: Effectiveness of eccentric exercise. Br J Sports Med
2007;41:188-98.

17. Howitt SD. Lateral epicondylosis: A case study of conservative care

utilizing ART and rehabilitation. J Can Chiropr Assoc 2006;50:182-9.

18. Finestone HM, Rabinovitch DL. Tennis elbow no more: Practical

eccentric and concentric exercises to heal the pain. Can Fam
Physician 2008;54:1115-6.

19. Fernández-Carnero J, Fernández-de-Las-Peñas C, de la Llave-Rincón

AI, Ge HY, Arendt-Nielsen L. Prevalence of and referred pain from
myofascial trigger points in the forearm muscles in patients with lateral
epicondylalgia. Clin J Pain 2007;23:353-60.

20. Groppel JL, Nirschl RP. A mechanical and electromyographical

analysis of the effects of various joint counterforce braces on the
tennis player. Am J Sports Med 1986;14:195-200. [PUBMED]

21. Jafarian FS, Demneh ES, Tyson SF. The immediate effect of orthotic
management on grip strength of patients with lateral epicondylosis. J
Orthop Sports Phys Ther 2009;39:484-9.

22. Strujis PA, Damen PJ, Bakker EW, Blakenbvoort L, Assendelft WJ,
van Dijk CN. Manipulation of the wrist for management of lateral
epicondylitis: A randomized pilot study. Phys Ther. 2003;837:608-16.

23. Vicenzino B, Cleland JA, Bisset L. Joint manipulation in the

management of lateral epicondylalgia: A clinical commentary. J Man
Manip Ther 2007;15:50-6. [PUBMED]

24. Connell D, Datir A, Alyas F, Curtis M. Treatment of lateral epicondylitis

 using skin-derived tenocyte-like cells. Br J Sports Med 2009;43:293-8.

25. Chesterton LS, Mallen CD, Hay EM. Management of tennis elbow.
Open Access J Sports Med 2011;2:53-9.

26. Bhatt JB, Glaser R, Chavez A, Yung E. Middle and lower trapezius
strengthening for the management of lateral epicondylalgia: A case
report. J Orthop Sports Phys Ther 2013;43:841-7.

27. Johnson GW, Cadwallader K, Scheffel SB, Epperly TD. Treatment of

lateral epicondylitis. Am Fam Physician 2007;76:843-8.

28. Robinson J. Treatment options for tennis elbow. B C Med J

2013;55:381-93.

29. Chesterton LS, Mallen CD, Hay EM. Management of tennis elbow. J
Sports Med 2011;8:53-9.