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The lowdown on tennis elbow
By: Dr. Kerrie Evans (profile)
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Karen Lunn has played on the Ladies European Tour for more than 20 years and like many professional golfers, has suffered from a number of injuries throughout her career. However, it was elbow pain that threatened to end the career of the former British Open Champion.

Stiffness through Karen’s thoracic spine (middle back)
prevented her from turning properly during the
back swing, creating a steep downswing which
put pressure on her left elbow through the impact area.

Karen Lunn has played on the Ladies European Tour for more than 20 years and like many professional golfers, has suffered from a number of injuries throughout her career. However, it was elbow pain that threatened to end the career of the former British Open Champion. Karen Lunn’s elbow pain began as a ‘niggly’ pain around the outside of her left elbow and, at least initially, wasn’t interfering with her golf. Unfortunately, the pain progressively increased over a period of three months and by the end of the 2006 European season, became so severe she couldn’t pick up a club, carry her bag or even turn on a tap. Karen returned to Australia having been diagnosed with “tennis elbow”. Tennis elbow is an umbrella term generally used to describe any pain that is experienced around the outside or lateral part of the elbow. Tennis elbow is sometimes called lateral epicondylalgia, which literally means pain on the outside of the elbow. It is also commonly referred to as lateral epicondylitis. However, lateral tendinopathy was the underlying pathology resulting in Karen’s elbow pain. Tendinitis vs Tendinopathy Any condition with an ‘-itis’ at the end of the name indicates the presence of inflammation (eg appendicitis – inflammation of the appendix). In tendinopathies, degenerative changes are present within the tendon such that the tendon loses its normal structure, but there are no typical inflammatory cells present. That is why, when lateral elbow pain results from lateral tendinopathy rather than lateral epicondylitis, treatments directed towards treating inflammation (eg ice, ultrasound) often fail – because there is no inflammation present! Treatment for tendinopathy is quite different and usually involves a program of specific tendon-loading exercises. Lateral elbow tendinopathy (LET) In LET, the most frequently involved muscle is the extensor carpi radialis brevis (ECRB for short!). This muscle attaches to the outside bony part of the elbow, which is where the pain of LET is commonly felt. As was the case with Karen, the pain can begin gradually and be aggravated by lifting, carrying or gripping objects.

During the time Karen had away from golf,
she worked on improving her flexibility through
the thoracic spine, enabling her to make a
better shoulder turn.

LET is common amongst golfers – in fact, more common than golfer’s elbow (an umbrella term describing pain on the inside of the elbow). LET is more often experienced in the lead elbow (left elbow for a right-handed golfer) and is actually more common in amateur golfers than professional golfers. LET is not limited to golfers – it is common amongst tennis players and workers required to perform repetitive hand tasks. Although, LET can occur at any age, the peak incidence of LET occurs between 30 and 50 years of age – remember the underlying pathology of tendinopathy is that of degenerative changes within the tendon (don’t we all hate that word!) and so is less common in young tendons. Thus, a diagnosis of tendinopathy is typically based on: • duration of signs and symptoms • age of the patient • predisposing factors (eg previous work history) • physical examination results (eg pain over the lateral elbow, and pain with gripping, resisted wrist extension and on resisted middle finger extension). In most cases, x-rays are not necessary – diagnosis is based on a person’s clinical signs and symptoms.

extensor carpi radialis brevis
Diagram courtesy Elsevier Ltd.

Risk factors Many risk factors for LET in golfers have been proposed. Few of these have been examined experimentally. However, in Karen’s case, a number of factors probably contributed to her injury. Karen was spending a lot of time hitting off mats (wet mats no less – she was practising in England at the time!). Hitting off mats increases the vibration the elbow experiences. Overuse is considered to induce LET but may not be the root cause of the pathology. Nevertheless, the combination of an increase in practice time on top of 20 years of professional golf would definitely increase the load borne by the elbow. With respect to ‘swing’ factors, Karen has always struggled with stiffness in the middle part of her back (the thoracic spine). This can make it difficult to achieve adequate turn during the swing. One strategy to compensate for this is to do more work with the arms, which can significantly affect the forces around the elbow joint. A number of other technical and/or physical issues may increase the risk of developing elbow pain. In addition to overuse, poor swing mechanics (including poor sequencing and timing, excessive grip pressure and poor swing posture), ill-fitting clubs, old grips, failure to warm up before playing or practising and lack of physical fitness for golf have all been suggested to increase the chance of developing elbow pain. Treatment for lateral elbow tendinopathy Treatment options proposed for LET include specific exercise programs, massage, elbow braces, acupuncture, ultrasound, corticosteroid injections, prolotherapy (which involves injections of an irritant solution near the painful region of the tendon), and even surgery. The key to any successful treatment is to first receive an accurate diagnosis. The second is to seek advice from an experienced practitioner who understands the pathology of LET and as importantly, understand the demands golf places on your elbow. LET can be very difficult to treat and slow to improve. In Karen’s case, it took three months without playing golf, a further two months of physiotherapy treatment and a course of prolotherapy before she could return to playing and practising at her pre-injury level. Final word There is nothing worse than having to take time off golf because of an injury. Karen has returned to the Ladies European Tour this year with a happy, pain-free elbow. As with many injuries, prevention is better than cure. If you notice any elbow pain, whether it be during or after golf or completely unrelated to your game, seek advice from a qualified health practitioner. And don’t be surprised if they use the term lateral epicon-dylalgia … that’s a whole other story!

Acknowledgements The Ladies European Tour wishes to thank Women's Golf Magazine, Australia, for allowing us to reproduce this article. Please click on the link below for details on how to subscribe to the magazine. subscription

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