Sports Med 2006; 36 (2): 151-170

REVIEW ARTICLE 0112-1642/06/0002-0151/$39.95/0

© 2006 Adis Data Information BV. All rights reserved.

Epicondylar Injury in Sport

Epidemiology, Type, Mechanisms, Assessment, Management
and Prevention
Patria A. Hume,1 Duncan Reid2 and Tony Edwards3
1 Institute of Sport and Recreation New Zealand, Division of Sport and Recreation, Faculty of
Health and Environmental Sciences, Auckland University of Technology, Auckland,
New Zealand
2 Division of Rehabilitation and Occupation Studies, Faculty of Health and Environmental
Sciences, Auckland University of Technology, Auckland, New Zealand
3 adidas Sport Medicine, University of Auckland, Auckland, New Zealand

Contents
Abstract . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 152
1. Definition of Epicondylar Injury . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 152
2. Epidemiology of Epicondylar Injury . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 153
2.1 Types of Sports with High Incidence of Epicondylar Injury . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 153
2.2 Possible Risk Factors for Epicondylar Injury . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 153
3. Assessment and Diagnosis of Epicondylar Injury . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 154
3.1 Determining Clinical Findings: Signs and Symptoms of Epicondylar Injury . . . . . . . . . . . . . . . . . . . 154
3.2 Determining Injury Cause: Mechanisms and Pathophysiology of Epicondylar Injury . . . . . . . . . 154
3.2.1 Lateral Epicondylar Injury (Tennis Elbow) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 155
3.2.2 Medial Epicondylar Injury (Golfer’s Elbow) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 155
3.2.3 Posterior Triceps Injury . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 155
3.2.4 Anterior Biceps Injury . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 156
3.2.5 Entrapment Neuropathy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 156
3.2.6 Ligament Injury . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 156
3.3 Assessment Tools . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 157
3.3.1 Pain and Disability Characterisation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 157
3.3.2 Joint Range of Motion and Strength Characterisation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 157
3.4 Diagnostic Tests . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 158
3.4.1 Magnetic Resonance Imaging . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 158
3.4.2 CT Arthrogram . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 158
3.4.3 Electrodiagnostic Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 159
4. Management of Epicondylar Injury . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 159
4.1 Relieving Inflammation and Pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 159
4.1.1 Use of R.I.C.E and Avoidance of H.A.R.M.Ful Factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 159
4.1.2 NSAIDs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 160
4.1.3 Corticosteroid Drugs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 160
4.2 Promoting Healing and Restoration of Function . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 160
4.2.1 Myofascial Techniques/Soft Tissue Mobilisation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 161
4.2.2 Massage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 162
4.2.3 Extracorporeal Shockwave Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 162
4.2.4 Laser Therapy and Acupuncture . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 162
4.2.5 Muscle Strengthening . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 162
4.2.6 Operative Treatments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 164
4.3 Effectiveness of Injury Management Protocols . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 164
5. Injury Prevention of Epicondylar Injury . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 166
5.1 Training Volume, Intensity and Duration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 166
152 Hume et al.

5.2 Biomechanics, Equipment and Technique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 166

6. Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 167

Abstract Epicondylar injuries in sports with overhead or repetitive arm actions are
frequent and often severe. Acute injury that results in inflammation should be
termed epicondylitis and is usually the result of large valgus forces with medial
distraction and lateral compression. Epicondylosis develops over a longer period
of time from repetitive forces and results in structural changes in the tendon.
Epicondylalgia refers to elbow pain at either the medial or lateral epicondyl of the
elbow related to tendinopathy of the common flexor or extensor tendon origins at
these points. Pain is usually associated with gripping, resisted wrist extension and
certain movements such as in tennis and golf, hence the common terms ‘tennis
elbow’ (lateral epicondylsis) and ‘golf elbow’ (medial epicondylossi). A variety
of assessment and diagnostic tools are available to aid the clinician in their
comprehensive evaluation of the patient to ensure correct diagnosis and the
appropriate conservative or surgical management strategy. Corticosteroids and
elbow straps are often used for treatment; however, there is only very limited
prospective clinical or experimental evidence for their effectiveness. The most
effective modalities of treatment are probably rest (the absence of painful activity)
combined with cryotherapy in the acute stage then NSAIDs and heat in its various
modalities including ultrasound. Cortisone injections may be used to create a
pain-free window of opportunity to optimise the athletes’ rehabilitation exercises.
Medical practitioners should have a good understanding of the mechanisms of
injury in order to help treat and prevent the re-occurrence of injuries. More
emphasis by medical and sport science personnel working with coaches and
athletes needs to be placed on prevention of elbow injury in sport through
improved joint strength, biomechanically sound sport technique and use of
appropriate sport equipment.

This article describes the epidemiology, patho-
physiology, mechanisms, assessment, management
and prevention of common epicondylar injury types
(lateral and medial epicondylitis, epicondylosis,
epicondylalgia and peripheral nerve entrapment) in
sport.
Literature was located using two computer
databases (MEDLINE and SportDiscus) in addition
to manual journal searches. The computer databases
provided access to sports-oriented and biomedical
journals, serial publications, books, theses, confer-
ence papers and related research published since
1948. The keywords searched included ‘injury’, ‘el-
bow’ and ‘sport’. Articles were excluded that were
not published in English and/or in scientific jour-
nals. The criteria for inclusion included:
• the paper must have addressed elbow injury in
sport;
• the paper may have been a review of previous
research.
A total of 122 journal articles, six books, two
conference abstracts and one thesis are included in
this review.
Elbow injuries in athletes cause pain, impairment
of function, and time loss from sport participa-
tion.[1,2] Lateral elbow pain[3] is seen more frequent-
ly than medial elbow pain.[4] Careful evaluation of
elbow pain is required to define the causes.[5] Know-
ing the cause of the elbow injury is important in
helping a player to avoid playing in pain.[6]
1. Definition of Epicondylar Injury
Elbow dysfunction may be related to acute or
chronic injury to the soft tissue or osseous compo-
nents of the elbow.[7] There are several terms used

© 2006 Adis Data Information BV. All rights reserved. Sports Med 2006; 36 (2)
Epicondylar Injury in Sport
interchangeably and incorrectly in the literature to
describe epicondylar injury such as epicondylitis,
epicondylosis and epicondylalgia. This literature re-
view has used ‘epicondylosis*’ when referring to
specific studies where the author has reported
epicondylitis, but it is not clear if it is indeed epicon-
dylitis rather than the correct term of epicondylosis.
The reader should acknowledge the inconsistency
used by previous authors, and should note our sug-
gested terminology:
• acute injury that results in inflammation should
be termed epicondylitis and is usually the result
of large valgus forces with medial distraction and
lateral compression;
• epicondylosis or epicondylopathy develops over
a longer period of time from repetitive forces and
results in structural changes in the tendon;
• epicondylalgia refers to elbow pain at either the
medial or lateral epicondyl of the elbow related to
tendinopathy of the common flexor/pronator or
extensor tendon origins, respectively, at these
points.
Kraushaar and Nirschl[8] have suggested there are
four stages of injury. Stage 1 shows distinct injury
with a normal inflammatory response and resolution
– this stage corresponds to epicondylitis. Stage 2
injury is from repeated microtrauma over time and
corresponds to epicondylosis. Stage 3 is a partial
tear plus fibrosis, tendinosis and calcification and
corresponds to epicondylalgia. Stage 4 is a continua-
tion of stage 3 but with a complete tear.
2. Epidemiology of Epicondylar Injury
With the popularity of racquet and throwing
sports, the number of individuals seeking medical
care for elbow pain and dysfunction is high. Esti-
mates of 50% elbow injury for athletes using over-
head arm motions have been suggested,[5] with
1–3% of the general population experiencing elbow
injury.[9] In New Zealand, the national insurer (Acci-
dent Compensation Corporation) reported 250
claims and $NZ1 125 148 for sport elbow injuries in
2004.
© 2006 Adis Data Information BV. All rights reserved.
153
2.1 Types of Sports with High Incidence of
Epicondylar Injury
Lateral epicondylosis* is common in ath-
letes[10,11] of all ages and skill levels due to increas-
ing participation in sports involving overhead arm
motions.[5,12] Epidemiological studies have reported
elbow injury for tennis,[13-16] windsurfing,[17] rock
climbing,[18] javelin throwing,[19] team handball[20]
and wheelchair athletes.[21] Case studies of elbow
injury have been reported for baseball pitching[4]
and cycling.[22] There have also been subjective
reports of elbow injury in weightlifters[23,24] and
racquet sport athletes.[5]
Athletic groups with a high incidence of elbow
pain have resulted in terms such as ‘tennis el-
bow’,[25-29] ‘gymnast’s elbow’,[30] ‘little league
pitchers elbow’,[31,32] ‘golfer’s elbow’[6] and ‘hand-
ball goalie’s elbow’.[20,33] ‘Handball goalie’s elbow’
has been defined as pain due to repetitive forced
hyperextension of the elbow.[20] Tyrdal and Bahr[20]
described team handball goalie’s elbow based on
questionnaire data from 329 coaches of senior and
junior teams in Norway in 1992. Over 45% of
goalkeepers and 4% of court players were reported
by their coaches to have current or previous symp-
toms from one or both elbows when playing hand-
ball. In response to a second questionnaire sent to
729 goalkeepers, 41% reported current elbow
problems and an additional 34% reported previous
problems. During a 2-year prospective study
(1992–4) 9% of the goalkeepers with previously
healthy elbows experienced elbow problems (recur-
rent pain and disability episodes with an acute onset
from hyperextension trauma).
2.2 Possible Risk Factors for Epicondylar Injury
Age and level of performance play a significant
role in elbow injury. Prevalence of chronic lateral
epicondylosis* seems to be greater in novice than in
expert tennis players.[34] Approximately 30–50% of
recreational tennis players can expect to get ‘tennis
elbow’ at some time during their playing lifetime.[35]
In one-third of the players, this will be severe
enough to interfere with their tasks of daily living.
Peak incidence of tennis elbow is between the ages
of 35–55 years,[9] but it is unknown why this age
group is susceptible to injury, and why 90% of
Sports Med 2006; 36 (2)
154
players have no further recurrence.[36] Kamien[28]
reported tennis elbow in 260 long-time tennis play-
ers (aged 10–79 years, average of 27 years playing
tennis) at a major Western Australian tennis club.
Retrospective questionnaire and interview data
showed that 59% of men and 52% of women report-
ed at least one period of tennis elbow when the
definition of tennis elbow was ‘having had pain on
either side of the elbow, which has caused discom-
fort or disability when playing tennis’. The mean
duration of pain was 36 weeks with 88% of those
affected, having only one episode of elbow pain. In
half of the cases, the onset of pain was sudden and in
over half of the cases the pain was severe enough to
prevent play. Beginning tennis at a relatively early
age seemed to protect against the development of
tennis elbow. Interestingly, tennis elbow was report-
ed as more common with increasing years of play,
age and in women who engaged in concurrent hob-
bies such as knitting, macramé and gardening.[28]
3. Assessment and Diagnosis of
Epicondylar Injury
Elbow injuries not only cause pain and disability
in young players, but also can lead to problems later
in life. Proper diagnosis and treatment, therefore, are
paramount.[32] An accurate, detailed history and
physical examination, combined with appropriate
imaging studies are essential in pinpointing the inju-
ry process (mechanisms and pathophysiology) and
making a specific diagnosis.[37] Accurate diagnosis
of elbow disorders depends on a thorough under-
standing of the types of injuries typically found in
the overhead athlete as well as a working knowledge
of the anatomy of the elbow.[37] For lateral epicon-
dylosis*, detailed evaluation and consideration of
neuropathy is an important factor in the diagnostic
process.[38] Acute elbow injuries are often collision
related; chronic elbow injuries typically stem from
overuse and valgus stress. What seems a purely
traumatic injury, though, may actually represent an
acute-on-chronic process.[39]
3.1 Determining Clinical Findings: Signs and
Symptoms of Epicondylar Injury
Important details in the clinical history are the
quality, intensity, and onset of pain and the location
© 2006 Adis Data Information BV. All rights reserved.
Hume et al.
of symptoms and their effect on function. Symptoms
and signs can include swelling, pain, dislocation,
restricted movement, tenderness, or valgus instabili-
ty when forearm flexors are contracted against resis-
tance.[40] Lateral elbow symptoms can result from
lateral epicondylosis, lateral collateral ligament in-
jury, radial nerve trauma, or any combination of
these injuries. Medial elbow symptoms can result
from medial epicondylosis, medial collateral liga-
ment injury, ulnar nerve trauma, or any combination
of these injuries.[3,5] Epiphyseal injuries, osteochon-
dritis and ulnar neuropathy also occur.[41] Pain is
more than twice as common on the lateral as on the
medial side of the elbow.[28]
The clinical examination should include visual
inspection of valgus or varus angulation of the el-
bow, muscle bulk, local bruising or swelling, and
skin discoloration (lack of skin pigmentation from
previous cortisone injections). Palpation, range of
motion (ROM), and key tests such as applying val-
gus stress are usually included.[39] Associations be-
tween pain, grip strength, and manual tests in the
treatment evaluation of chronic tennis elbow have
been shown.[42] Distal neurological examination
should be conducted for acute injury.
3.2 Determining Injury Cause: Mechanisms
and Pathophysiology of Epicondylar Injury
Elbow injury can be acute or chronic and results
from musculoskeletal stress at the elbow joint result-
ing in muscle, tendon, ligament, or bone. Because of
the biomechanics of the elbow joint, the lateral
compartment is exposed to compression forces
while the medial compartment works under traction
forces because of the physiological valgus. Struc-
tures most frequently damaged are the tendons that
insert into the epicondyles of the humerus.
The types of tendonopathies include epicon-
dylitis (inflammation), epicondylosis or epicon-
dylopathy (structural changes in tendon) and
epicondylalgia (tendonopathy). From an aetiologi-
cal perspective, the most common theory is that
epicondylalgia is a degenerative condition charac-
terised by tissue damage and leading to fibrillation
of collagen. Areas of hypervascularity are seen,
there is an absence of inflammatory cells and gener-
ally a poor response to healing with a loss of teno-
cytes (cells that encourage tendon growth) leading
Sports Med 2006; 36 (2)
Epicondylar Injury in Sport
to tendon thickening, persistent pain and loss of
function. On histological examination, the tendon
appears dull and grey in appearance, the collagen
disorganised and loosely woven, non-parallel in ar-
rangement and unable to withstand high tensile
forces.
Epicondylosis* plagues a significant proportion
of athletes and can result in prolonged symptoms
and suboptimal athletic performance. The diagnosis
may be confused with a variety of other pathological
entities affecting the elbow, some of which may
occur concurrently.[43] Chronic lateral epicon-
dylosis* usually shows more pain and more muscle
function impairment of the arm for patients than for
patients with chronic medial epicondylosis*.[44]
3.2.1 Lateral Epicondylar Injury (Tennis Elbow)
The term ‘tennis elbow’ has been used to de-
scribe both acute and chronic conditions associated
with lateral epicondylitis and epicondylosis.[9,26,45]
Lateral epicondylosis* is seen most often of all
elbow pain.[5] Gerber[46] interviewed and clinically
examined 46 world-class tennis players. Twenty
percent of the players had elbow pain with 70%
having pain about the medial humeral epicondyle
and 40% with lateral epicondylalgia.
Lateral epicondylosis* resulting in pain over the
lateral epicondyle occurs from a torque injury or
overstretching, due to the excessive use of the wrist
extensor musculature, of tendons that insert into the
epicondyles of the humerus.[36] Pathological tissue
changes result from fibroblastic degeneration.[34]
Repetitive microtraumatic injury can lead to mucin-
oid degeneration of the extensor origin and subse-
quent failure of the tendon.[12] Lateral humeral
epicondylosis* is characterised by pain in the area
where the common extensor muscles (especially
extensor carpi radialis brevis) meet the lateral hu-
meral epicondyle (i.e. pain in the outer compartment
of the elbow).[5,27,47,48] A lack of strength and func-
tion of the elbow and wrist are associated with
lateral elbow pain.[49]
Differential diagnoses for lateral epicondylosis
include radial nerve entrapment and elbow joint
disease. There are a number of other local patholo-
gies that may mimic tennis elbow including entrap-
ment of the interosseous nerve,[50] osteochondritis
dessicans of the radiohumeral joint,[51] intra-articu-
© 2006 Adis Data Information BV. All rights reserved.
155
lar body following trauma[51] ulnar collateral liga-
ment damage[52] or partial or complete tear of the
tendon.[52] Other extrinsic causes of pain are cervical
dysfunction and nerve root compression, other co-
existing pathologies given the age group that those
with tennis elbow fall into, and muscle imbal-
ance.[53]
3.2.2 Medial Epicondylar Injury (Golfer’s Elbow)
Medial epicondylosis* commonly known as
‘golfer’s elbow’ is characterised by pain and tender-
ness at the flexor/pronator tendinous origin with
pathology commonly being located at the interface
between the pronator teres and flexor carpi radialis
origin. Pronation and wrist flexion results in medial
epicondyle pain. Golfers and tennis players often
develop this condition because of the repetitive
stress placed on the medial elbow soft tissues.[12]
Medial epicondylosis* in the throwing athlete
manifests itself as pain with or after a period of
throwing and is typically associated with a more
prolonged, frequent, or strenuous regimen.[54] Care-
ful evaluation is important to differentiate medial
epicondylosis* from other causes of medial elbow
pain.[12,55]
3.2.3 Posterior Triceps Injury
The extensor mechanism of the elbow can also be
a source of clinical dysfunction. The two areas of
concern include triceps insertional tendonopathy
and posterior impingement syndromes. Two prima-
ry processes may affect the triceps tendon. Triceps
insertional tendonopathy, and triceps avulsion inju-
ries are the most common. Triceps tendonopathy,
the more common of the two, is manifested by
chronic posterior elbow pain with extension activi-
ties. Triceps tendonopathy occurs almost exclusive-
ly in males, usually in the fourth decade of life, and
especially in individuals who perform forceful re-
petitive extension activities, e.g. throwing athletes.
Two distinct subsets of patients exist: those with and
those without an olecranon traction spur.[56] While
triceps insertional traction osteophytes are often
seen in association with these clinical conditions,
osteophytes can also be seen in the asymptomatic
athlete. Posterior impingement is most commonly
seen in athletes with repeated extension activities
including repetitive throwing or repeated forced el-
bow extension in contact sport. These athletes will
Sports Med 2006; 36 (2)
156
complain of pain on forced extension of the elbow
and will notice they have a loss of end-range exten-
sion.
3.2.4 Anterior Biceps Injury
The typical history for distal biceps brachii rup-
ture involves a single traumatic event, an audible
popping sound, and intense pain.[57,58] The physical
exam reveals ecchymosis in the antecubital area and
weakness with both supination and elbow flexion.
The distal biceps brachii tendon will not be palpable,
although the aponeurosis can often be palpated,
which can confuse the diagnosis. Although distal
biceps rupture is far less common than its proximal
counterpart, primary-care physicians should be
aware of the diagnostic criteria.[59] Referral for sur-
gical treatment is necessary to preserve elbow flex-
ion and supination strength. A case study of distal
biceps rupture in a snowboarder has been report-
ed.[60]
3.2.5 Entrapment Neuropathy
Compressive or entrapment neuropathies of the
median, ulnar and radial nerves in the region of the
elbow are the common non-traumatic peripheral
nerve disorders among athletes[61] and are a frequent
cause of pain and weakness as well as sensory
complaints.[62] Upper extremity peripheral nerve en-
trapments resulting in hand pain and numbness is
prevalent (23–64%) among wheelchair athletes.[63]
Entrapment neuropathies are often overlooked be-
cause localised neural pain may be attributed to
musculoskeletal injury. ‘Resistant tennis elbow’
may be due to posterior interosseous nerve entrap-
ment on the lateral side of the elbow and may give
rise to similar symptoms to lateral epicondylosis*
making the diagnosis difficult.[48,61] Prompt recogni-
tion of the problem and the specific site of compres-
sion are important in order to institute effective
treatment[64] and limit, if not totally eliminate, per-
manent sequelae.[62]
Excessive valgus stress can lead to posteromedial
olecranon impingement on the olecranon fossa (me-
dian nerve entrapment neuropathy) producing pain,
osteophyte and loose body formation. Disability du-
ration has been correlated significantly with elec-
trophysiological median nerve dysfunction in 28
wheelchair athletes.[63] A case of ulnar neuritis (ul-
nar nerve entrapment neuropathy) in the throwing
© 2006 Adis Data Information BV. All rights reserved.
Hume et al.
arm of a baseball pitcher emphasised the need for an
accurate physical examination and knowledge of
surgical anatomy.[41]
Chronic lateral elbow pain caused by radial nerve
entrapment neuropathy is called radial tunnel syn-
drome.[65] Radial tunnel syndrome is an infrequent
condition that may produce symptoms similar to
tennis elbow; however, radial tunnel syndrome is
distinguished from lateral epicondylosis* (tennis el-
bow) in that the symptoms are present >6 months
and resistant to conservative treatment.[66] Three
pathognomomic signs indicate radial tunnel syn-
drome: (i) tenderness when palpating the radial tun-
nel anterior to the neck of the radius; (ii) reproduc-
tion of symptoms with resisted supination; and (iii)
lateral elbow pain with resisted extension of the
ipsilateral middle finger.
Lateral ante brachial cutaneous neuropathy is an
uncommon, but easily overlooked, cause of elbow
pain in the throwing athlete. Compression of the
lateral ante brachial cutaneous nerve by the biceps
tendon occurs at the nerve’s exit point from the
brachial fascia just proximal to the elbow flexion
crease. Symptoms include pain in the anterolateral
elbow and burning dysesthesias radiating into the
lateral forearm, particularly when the forearm is
fully pronated with the elbow extended.[67]
Another cause of pain around the lateral epicon-
dyle may be the development of secondary hyperal-
gesia. Vicenzino[68] suggested that secondary hyper-
algesia represents disordered neural processing
characterised by central sensitisation. This implies
that the pain is felt in an area that is neurologically
related to but not at, the injured tissue site. The
involvement of the cervical spine and upper limb
neural tissues[50] may contribute to this type of pain
and to the perpetuation of chronic lateral epicondy-
lalgia. Therefore, clinicians should evaluate other
sources of pain more proximal to the elbow when
symptoms persist.
3.2.6 Ligament Injury
A less common cause of medial elbow pain is
medial ulnar collateral ligament injury. Repetitive
valgus stress placed on the joint can lead to micro-
traumatic injury and valgus instability. When the
medial ulnar collateral ligament is disrupted, abnor-
mal stress is placed on the articular surfaces that can
Sports Med 2006; 36 (2)
Epicondylar Injury in Sport
lead to degenerative changes in the radial/humeral
joint with osteophyte formation.[12] Injury of liga-
ments and muscles on the ulnar side following insta-
bility of the medial side of the elbow in 33 ath-
letes[40] has been reported.
Timmerman and Andrews[69] were the first to
report a lesion of the anterior bundle of the ulnar
collateral ligament associated with persistent medial
elbow pain in throwing athletes. Under-surface tears
of the deep capsular layer of the anterior bundle of
the ulnar collateral ligament in seven baseball play-
ers[69] resulted in tenderness over the anterior bundle
of the ulnar collateral ligament and pain with valgus
stressing of the elbow. Six of the patients had a
normal magnetic resonance imaging (MRI) scan,
with one MRI scan showing degeneration within the
ligament. Five of the seven patients had a leak of
contrast around the edge of the humerus or ulnar in a
negative CT arthrogram for extra capsular contrast
extravasation. At arthroscopy evaluation, all of the
patients demonstrated medial elbow instability as
valgus stress was applied across the elbow joint in
70° flexion. All patients showed the ulnar collateral
ligament intact externally during open medial elbow
surgery, but when the anterior bundle was incised,
there was a detachment of the under-surface of the
ligament at the ulnar or the humerus. Timmerman
and Andrews[69] concluded that a tear of the deep
layer of the ulnar collateral ligament could result in
symptomatic instability that is difficult to diagnose
with conventional preoperative testing.
3.3 Assessment Tools
3.3.1 Pain and Disability Characterisation
Visual analogue scales, pain and disability ques-
tionnaires, pain threshold tests, size of pain draw-
ings and a 100-point scoring system have been used
to evaluate subjective results for patients. These
various pain scores have been used to quantify the
severity of elbow injury and to monitor the effec-
tiveness of rehabilitation protocols.
A seven-item pain and disability questionnaire
visual analogue scale has been used to assess pa-
tients with medial epicondylosis* (6.7cm pain
score) compared with patients with lateral epicon-
dylosis* (7.9cm) when the elbow was placed under
strain.[44] Ten patients with unilateral radial epicon-
© 2006 Adis Data Information BV. All rights reserved.
157
dylalgia showed a significant improvement for the
visual analogue pain scale for initial assessments (5
± 3) compared with final assessments (1 ± 3).[70] An
analogue scale was used to analyse pain intensity,
and pain occurrence was evaluated by a pain phase
scale.[71] All patients reported partial or complete
pain relief postoperatively (improvement in their
pain phase and pain intensity scales). Preoperative-
ly, 14 patients had pain at rest; all 14 had relief of
this pain postoperatively. The size of pain drawings
has shown larger pain areas for patients with medial
epicondylosis* (1.9cm) than patients with lateral
epicondylosis* (2.5cm).[44]
Dolorimeter measurements of cubital pressure
pain thresholds of medial epicondyles were 54%
lower in medial epicondylosis* than in lateral
epicondylosis*.[44] Ten patients with unilateral radi-
al epicondylalgia showed a significant improvement
for painful force threshold over the lateral epicon-
dyle for initial assessments (49 ± 22%) compared
with final assessments (94 ± 14%).[70] Patient satis-
faction, grip strength, and elbow function and a
1–10 pain scale score have been recorded.[72] A
100-point scoring system was used to evaluate sub-
jective (pain, swelling, locking and activities) and
objective (ROM) results for 19 patients with post-
traumatic arthrofibrosis of the elbow. The average
preoperative subjective score of 39 improved signif-
icantly to 91 postoperatively, and the objective score
improved significantly from 46 preoperatively to 81
postoperatively.[73] These examples of pain scores
indicate the usefulness of monitoring pain to show
improvement in elbow pain after treatment.
3.3.2 Joint Range of Motion and
Strength Characterisation
Elbow extension is very critical for the throwing
athlete. In lateral epicondylosis*, supination and
pronation have been reduced by 10% and 15% in 25
patients with chronic unilateral lateral epicon-
dylosis*.[44] ROM is a good measure for the effec-
tiveness of treatments. For example, ten patients
with unilateral radial epicondylalgia showed signifi-
cant improvement for active wrist extension ROM
for initial assessments (83 ± 13%) compared with
final assessments (96 ± 10%).[70] Extension in 19
patients with post-traumatic arthrofibrosis of the
elbow improved from a mean of 29° to 11°, and
Sports Med 2006; 36 (2)
158
flexion improved from an average of 123° to
134°.[73]
Valgus stress is applied with the throwing mech-
anism, which can overload the flexor pronator
mass.[54] Injuries to the ulnar collateral ligament can
result from repeated valgus stress to the elbow.[74]
Medial elbow instability can be demonstrated dur-
ing examination as valgus stress is applied across
the elbow joint in 70° flexion.[39,69]
The Marcy Wedge-Pro™ 1 is a device used in
training by tennis players, and has been employed in
the quantitative assessment of tennis elbow.[75] The
Marcy Wedge-Pro™ measures the ability of patients
to perform wrist extension exercises, since pain
resulting from wrist extension is a prominent symp-
tom of elbow injury. The Marcy Wedge-Pro™ iden-
tified accurately patients who responded to treat-
ment.
Force and ROM measurements from the involved
upper extremity normalised to values from the
uninvolved extremity are sensitive assessments of
patient progress following treatment for unilateral
radial epicondylalgia (tennis elbow).[70] In compari-
son with measurements of force and ROM that were
not adjusted to a baseline score, normalised mea-
surements detected changes in responses by ten pa-
tients when baseline scores varied.
Grip strength (mean and maximal) can be mea-
sured to assess elbow injury.[44] It has been suggest-
ed that an average of grip strength measurements
recorded from multiple test sessions is preferred
rather than by increasing the number of grip strength
repetitions during a single test session.[76] Ten pa-
tients with unilateral radial epicondylalgia showed a
significant improvement for grip strength for initial
assessments (78 ± 26%) compared with final assess-
ments (101 ± 20%).[70]
Peak torque values have been used to assess
initial loss of function and to evaluate progress in
rehabilitation. Peak torque at a radial velocity of
90°/sec, and work in wrist flexion has been signifi-
cantly reduced by 13% and 17% in medial epicon-
dylosis* and lateral epicondylosis*, respectively.[44]
Ten patients with unilateral radial epicondylalgia
showed a significant improvement for isometric
1 The use of trade names is for product identification purposes only and does not imply endorsement.
© 2006 Adis Data Information BV. All rights reserved.
Hume et al.
wrist extension forces for initial assessments (68 ±
24%) compared with final assessments (95 ±
35%).[70] Objective dynamometer strength testing
has revealed a significant improvement postopera-
tively in patients.[71]
3.4 Diagnostic Tests
Diagnostic tests for epicondylar injury include
MRI, radiographic evaluation, CT arthrogram, bone
scans and electrodiagnostic assessment. The physi-
cian should consider the cost-benefit of the diagnos-
tic test.
3.4.1 Magnetic Resonance Imaging
MRI allows accurate determination of the nature
and extent of the pathological changes in ligaments,
tendons, muscles and osseous structures (bone mar-
row and hyaline cartilage) of the elbow joint.[7,77]
MRI may help establish the cause of elbow pain by
accurately depicting the presence and extent of bone
and soft tissue pathology, and facilitate the choice of
the appropriate therapeutic regimen. MRI can help
identify an avulsion fracture not visible radiographi-
cally and can help determine whether direct repair or
reconstruction is needed.[74] Osseous stress injury of
the posteromedial aspect proximal ulnar has been
reported as a cause of elbow pain in seven profes-
sional baseball players. Plain radiographs of the
involved elbows failed to demonstrate any signifi-
cant findings, but MRI detected the clinically signif-
icant lesions. The ulnar collateral ligament was in-
tact in all seven athletes.[78]
3.4.2 CT Arthrogram
Timmerman et al.[79] reported that both CT ar-
throgram (86% sensitivity, 91% specificity) and the
MRI scan (57% sensitivity, 100% specificity) were
accurate in diagnosing a complete tear of the ulnar
collateral ligament pre-operatively in 25 baseball
players. The main advantage of the CT arthrogram
was in evaluating the partial undersurface tear (T-
sign). The T-sign represented dye leaking around
the detachment of the ulnar collateral ligament from
its bony insertion but contained within the intact
superficial layer of the ulnar collateral ligament and
capsule.
Sports Med 2006; 36 (2)
Epicondylar Injury in Sport
3.4.3 Electrodiagnostic Assessment
Electrodiagnostic assessment uses short-segment
stimulation techniques for the median nerve across
the carpal tunnel and the ulnar nerve across the
elbow. Electrodiagnostic assessment was more sen-
sitive than clinical assessment (64% vs 23%) in
determining prevalence of nerve entrapment for up-
per extremities of 28 wheelchair athletes and 30
able-bodied controls.[63] The most common elec-
trodiagnostic dysfunction was of the median nerve
at the carpal tunnel (46%) and the portion of the
nerve within the proximal carpal tunnel was most
frequently affected. Ulnar neuropathy was the sec-
ond most common entrapment electrodiagnostically
(39%) and occurred at the wrist and forearm seg-
ments.[63]
4. Management of Epicondylar Injury
Elbow injuries are common, therefore, any infor-
mation regarding the successful treatment/manage-
ment of these injuries has important implications for
the medical practitioner.[38] Effective treatment may
be rendered once an accurate diagnosis has been
made.[80] The prime aim of treatment should be
based on Hippocrates’ first tenet of medicine – first
do no harm. Therapy should start with the simple
and conservative before progressing to the more
complex and invasive therapies. Treatment should
be acceptable to the patient, cost-effective and
where invasive therapy is recommended, the poten-
tial benefits should clearly outweigh the risks.[36]
Management decisions should be based on the pa-
tient’s age and the stability, location and size of the
lesion.[81]
Like many other tendon injuries, the manage-
ment of lateral epicondylosis is challenging. The
work of Khan and Maffulli[57] with respect to patel-
lar tendinopathy, would indicate that although pa-
tients may present with acute symptoms, the degen-
erative nature of tendon pathology means that there
has usually been a period of failed tendon adaptation
to load through abusive training, for many months
before symptoms are felt. Therefore, not only does
the condition take many months to develop but
many months to resolve with bouts of recurrence,
vulnerability to re injury and increased pain likely
during the recovery phase, as the patient attempts to
return to activity. The degenerative nature of the
© 2006 Adis Data Information BV. All rights reserved.
159
tissue also means that some patients will not regain
full tendon integrity following the treatment.
It is somewhat difficult to study the natural histo-
ry of elbow injury since only half of the affected
subjects seek medical care.[34] The natural course of
the condition lasts about 18 months.[34] Management
options can be categorised into two broad stages. In
the first stage there is a need to reduce the pain
levels with local modalities. Management should
focus in the acute stage on relieving inflammation,
microbleeding and pain. This may involve de-
creased activity, ice and NSAID medications in the
first instance. In the second stage, there is a need to
gradually increase the tissue loading. The stage of
the healing process the patient is in needs to be
considered as work of Hunter[82] indicates that when
the tissue is injured it has a low tolerance to loading.
Manual therapy, using techniques such as specific
soft tissue mobilisation, can be used to increase the
loading on the tissue as the healing process takes its
course.
Eccentric strengthening, high-voltage galvanic
stimulation, forearm and arm exercises, and trying
to prevent recurrence by reducing overload forces
(counterforce brace, modification in playing tech-
nique and equipment, and muscle strengthening)
may be used during rehabilitation. The treatment
should have the goal of returning the athlete to
participation.[37]
4.1 Relieving Inflammation and Pain
4.1.1 Use of R.I.C.E and Avoidance of
H.A.R.M.Ful Factors
Many players do not want to restrict their sport-
ing time unless they can see that by continuing the
rehabilitation programme their injury will be over-
come.[38] Current best practice advice for initial
treatment of soft tissue injuries is based on the
principles of R.I.C.E. (Rest, Ice, Compression, Ele-
vation), while avoiding the H.A.R.M.ful factors
(Heat, Alcohol, Running, Massage).[83] The use of
ice is for the analgesic effects to reduce pain and
inflammation. Compression will also reduce the
swelling associated with the inflammation and will
reduce the pain caused by increased pressure in the
extra-cellular spaces. The most useful treatments for
elbow injury reported from the results of a retro-
Sports Med 2006; 36 (2)
160
spective questionnaire study of 260 long-time tennis
players were rest, heat, massage, aspirin (acetylsali-
cylic acid), naproxen, the application of ice after
play and the use of the clasp bandage around the
forearm.[28]
4.1.2 NSAIDs
NSAIDs are used either orally or by topical appli-
cation to reduce pain reduction. Green et al.[49] re-
viewed 14 studies that had assessed the effective-
ness of oral or topical NSAIDs in the treatment of
adults with lateral elbow pain with respect to pain
reduction, improvement in function, grip strength
and adverse effects. Topical NSAIDs were signifi-
cantly more effective than placebo with respect to
pain and participant satisfaction in the short term.
The reported adverse effects of topical NSAIDs
were minor. There was some evidence for short-
term benefit with respect to pain and function from
oral NSAIDs; however, those taking oral NSAIDs
reported gastrointestinal adverse effects. A direct
comparison between topical and oral NSAID has not
been made and so no conclusions can be drawn
regarding the best method of administration.
Jenoure et al.[84] tested the efficacy and tolerabili-
ty of a topical NSAID continuous delivery system,
diclofenac hydroxyethylpyrrolidine (epolomine)
[DHEP] tissugel plaster in the treatment of humero-
radial epicondyl pains of a strictly tendinopathic
nature in a multicentre, double-blind study. A total
of 85 patients (44 treated with DHEP tissugel plaster
and 41 with placebo) were observed during the
14-day treatment period and the 14-day treatment-
free follow-up period. Spontaneous pain, pain on
pressure, and pain on muscular testing improved in
both groups with longer lasting effects in the DHEP
tissugel plaster-treated group compared with the
placebo group.
A prospective, placebo-controlled, double-blind
trial of 60 patients with 50mg glycosaminoglycan
polysulfate injections or placebo injections (one in-
jection a week, for 5 weeks) showed the therapeutic
benefit of local glycosaminoglycan polysulfate in
the treatment of chronic epicondylalgia.[85]
A controlled, randomised, single-blind, mul-
ticentre study compared the efficacy and tolerance
of 246 patients with acute or acute-exacerbation of a
chronical radio-humeral bursitis to a dexametha-
© 2006 Adis Data Information BV. All rights reserved.
Hume et al.
sonepalmitate lipidmicrosphere emulsion to the con-
ventional dexamethasone-21-acetate crystal suspen-
sion injection. The second day after injection, 93
patients (75.6%) of the lipidmicrosphere group and
83 patients (69.5%) of the crystal suspension group
showed significant improvement concerning pain
following exercise. Both periarticular injections
were considered appropriate for patients with tennis
elbow.[86]
4.1.3 Corticosteroid Drugs
In the short term there may be some advantage in
corticosteroid injection over oral NSAID. Fichez[34]
indicated that local corticosteroid injections have
shown significant improvement in pain relief, dor-
siflexion resistance and grip force at 6 weeks for
tennis players.[34] However, corticosteroid injection
has been contraindicated for triceps tendonosis.[56]
Wiggins et al.[87] examined the biomechanical,
histological and biochemical effects of cortisone on
collangenous tissue in medial ligaments of NZ white
rabbits. Betamethasone was injected into the dam-
aged ligament. Within 10 days there were histologi-
cal changes evident with a significant reduction in
collagen synthesis and these were still present after
3 weeks. There was reduced tensile strength with a
50% reduction in peak load to failure following
cortisone injection. The clinical implications from
this study are that with cortisone there is poor quali-
ty scar tissues, less tensile strength and a reduction
in ground substance in the form of glucose amino
glycans. Although the cortisone reduces pain, there
may a high risk of tendon/ligament rupture if there is
active rehabilitation following cortisone injection.
4.2 Promoting Healing and Restoration
of Function
A variety of therapy techniques including my-
ofascial and soft tissue mobilisation techniques,
massage, high-voltage galvanic stimulation, ex-
tracorporeal shockwave treatment, laser therapy, ac-
upuncture and muscle strengthening are used to
modulate musculoskeletal pain and promote heal-
ing. A rehabilitation programme should be
progressed according to decrease in inflammation
and increase in ROM and strength.[88]
There have been limited studies on the evaluation
of the effectiveness of various treatment strategies
Sports Med 2006; 36 (2)
Epicondylar Injury in Sport
for the management of the variety of elbow injuries.
Most patients will respond favourably to a well
guided nonsurgical treatment protocol for lateral
epicondylosis*[43,89] including relieving pain, pro-
moting healing, reducing overload forces,[27,90] exer-
cise therapy and conditioning.[38] Patients with later-
al ante brachial cutaneous neuropathy are treated
conservatively with NSAID agents, rest, activity
modification and extension block splinting. For pa-
tients who do not respond to non-operative treat-
ment, surgical decompression of the nerve under
local anaesthesia provides complete relief of symp-
toms and return to full activity.[67] Conservative
management for triceps tendonosis involves avoid-
ance of repetitive forceful elbow extension,
NSAIDs, and time. Splinting in 45° elbow flexion
may be useful if tolerated.[56] Although conservative
management is limited in scope, it is usually suc-
cessful in triceps tendonosis in the absence of an
olecranon traction spur. The presence of an olecra-
non traction spur is associated with a higher failure
rate of conservative treatment necessitating surgical
intervention.[56]
4.2.1 Myofascial Techniques/Soft
Tissue Mobilisation
Treatment of elbow pain using myofascial tech-
niques[91,92] has shown limited success. Later anal-
gesic effects of spinal manual therapy on chronic
tendonopathy have been reported.[93]
Hunter[82] suggested a regime of three types of
specific soft tissue mobilisation (SSTM). Physiolog-
ical SSTM uses a stretch applied in the opposite
direction to the physiological action of the muscle.
In the case of tennis elbow injury to extensor carpi
radialis longus this will be elbow extension, forearm
pronation and wrist flexion. Accessory SSTM re-
quires stretch to be placed on the muscle at a right
angle to the muscle fibre direction rather than paral-
lel or on top of the muscle. Combined SSTM is a
combination of physiological and accessory SSTM
and as it exerts the most tension on tissue it is
usually used towards the later stages of treatment.
Often weight-bearing load can be introduced such as
Mulligan’s mobilisations with movement.[94] These
types of movement allow the application of lateral
glide while gauging the effectiveness of the treat-
ment by including a functional activity such as ask-
© 2006 Adis Data Information BV. All rights reserved.
161
ing the patient to grip at the same time the lateral
glide is applied.
There is some evidence of the effectiveness of
these types of treatments in relieving pain. A case
study[95] reported a manipulative physiotherapy
technique where a lateral glide of the elbow was
performed while the patient performed an activity
that usually aggravated the tennis elbow pain. A
2-week pre-treatment assessment phase, a 2-week
treatment phase (with four treatment sessions) and a
6-week post-treatment assessment phase showed a
reduction in pain (pain visual analogue scale and
pressure algometer) and increase in function (grip
dynamometer, function visual analogue scale and
pain-free function questionnaire) during and imme-
diately after the treatment.
The randomised, double-blind, placebo-con-
trolled, repeated-measures study by Vicenzino et
al.[96] of the initial effect of a manipulative lateral
glide therapy in 24 patients (mean age 46 years) with
unilateral, chronic lateral epicondylalgia (mean du-
ration 8.3 months) produced uniquely characteristic
hypoalgesia. The non-affected arm was used as the
control. Outcomes measured were pressure-pain
threshold and pain-free grip strength. The 2 days of
treatment consisted of six repetitions per day of
Mulligan’s mobilisations with lateral glide during
patient gripping. Pain-free grip strength increased
58% (107–156N) during treatment and pressure-
pain threshold increased 10% after treatment in the
affected limb but not for the placebo or control
patients.[96] A limitation of this study is that the
treatment was assessed only after 2 days. However,
the study does indicate that a decrease in pain in the
acute stages may result in a patient being able to
complete rehabilitation successfully with the pro-
motion of healing.
A later study[97] examined the initial effects of
elbow mobilisation with movement on grip strength
in 25 subjects with lateral epicondylalgia. Pain with
active motion, pain-free grip strength and maximum
grip strength were measured before and after a sin-
gle intervention of mobilisation with movement.
Pain-free grip strength and maximum grip strength
of the affected limb increased significantly follow-
ing the mobilisation with movement intervention.
Pain-free grip strength was a more responsive mea-
sure of outcome than maximum grip strength for
Sports Med 2006; 36 (2)
162
patients with lateral epicondylalgia. Pain-free grip
strength responses should be a good indicator for the
practitioner for the progression of rehabilitation.
4.2.2 Massage
Although authors have described how sports
massage techniques can be used to help athletes stay
healthy, recover from competition and perform at a
higher level[98] there is limited evidence that sports
massage techniques of compressive effleurage,
compressive petrissage, compression broadening,
deep transverse friction, active assisted massage
static compression and active assisted massage
lengthening and broadening can treat tennis elbow.
Rehabilitation including physiotherapy and deep
transverse massage has been reported to have shown
significant results for tennis elbow.[34] However,
massage has also been reported as not showing any
significant effects in reducing muscle sore-
ness.[99,100] More well designed studies on the effec-
tiveness of massage as a rehabilitation technique for
epicondylar injury are required.
4.2.3 Extracorporeal Shockwave Therapy
Extracorporeal shockwave treatment significant-
ly reduces pain and improves function compared
with placebo.[34] The application of extracorporeal
shock waves of varying intensity in chronic
tendonitis produced subjective pain improvement in
87% of 55 patients treated; however, five patients
showed no improvement.[101] Wang and Chen[102]
investigated the effect of shockwave therapy in 57
patients with lateral epicondylosis* of the elbow
after 1–2 years follow-up. Forty-three patients (24
men and 19 women, average age of 46 years) were
treated with 1000 impulses of shockwave therapy at
14kV to the affected elbow, and six additional pa-
tients were treated with a sham procedure as a
control group. A 100-point scoring system evaluated
pain, function, strength and elbow ROM. Twenty-
seven elbows (61.4%) were free of complaints, 13
(29.5%) were significantly better, 3 (6.8%) were
slightly better, and 1 (2.3%) was unchanged. In the
control group, the results were unchanged in all six
patients. There were no device-related problems and
no systemic or local complications.
4.2.4 Laser Therapy and Acupuncture
The efficacy of new modalities such as low-
energy laser, electro-acuscope, and neuroprobe to
© 2006 Adis Data Information BV. All rights reserved.
Hume et al.
promote healing and reduce the pain associated with
epicondylosis* remains controversial.[103] Laser
therapy has been reported as ineffective for lateral
epicondylosis* treatment when patients were as-
sessed for difference in pain, tenderness and
strength measures post-treatment.[104] Fichez[34] stat-
ed that low-level laser and acupuncture were of little
use in the management of tennis elbow. However,
acupuncture may modulate pain in the tendon at-
tached to the epicondyle with the ‘secondary epicon-
dylitis’ associated with certain forms of epicondy-
lalgia.[105] Escribano et al.[106] treated 15 amateur
tennis players with chronic epicondylosis* for >3
months using electroacupuncture at specific stan-
dard acupuncture points and at other metameric
points where symptoms were felt. During the treat-
ment period, patients who had not interrupted their
tennis playing were advised to rest for the first week.
Sporting activity was resumed in all cases from the
second week of treatment onwards. Pain relief re-
sults were very good in 53% of patients, good in
20% and either poor or non-existent in the remain-
ing 26%. Further experimental studies are required
to evaluate the effectiveness of laser treatment and
acupuncture for the treatment of elbow injury.
Therapies such as acupuncture have recently
been evaluated with respect to their effectiveness in
reducing the pain of tennis elbow and improvement
in function and grip strength.[49] The results of a
review of four small, randomised, controlled stud-
ies, suggested that there is a short-term benefit for
the reduction of pain but this was not lasting (<24
hours) and that further trials with larger sample sizes
will be required before stronger conclusions can be
drawn.[49]
4.2.5 Muscle Strengthening
A dynamic exercise programme that incorporates
functional rehabilitation, is a modern and accepted
method by both the patient and the clinician. Effec-
tive programmes need to be sport-specific to main-
tain the interest of the participant and yet at the same
time they need to be able to accommodate other
factors such as age, sex and the level of the player. It
is critical that the clinical practitioner has a funda-
mental knowledge of normal mechanics and a work-
ing knowledge of the musculoskeletal requirements
needed to produce sport movements.
Sports Med 2006; 36 (2)
Epicondylar Injury in Sport
Recent literature in the management of other
tendons such as the Achilles and patella tendon that
also experience degenerative tendinopathies, have
led to the introduction of eccentric exercise re-
gimes.[107,108] Vicenzino[68] has suggested that the
primary physical impairment in patients with lateral
epicondylalgia is best characterised as a decondi-
tioning response of the forearm muscles to pain. It
has been suggested that a lack of control of eccentric
pronation in the forearm can result in injury due to
the increased stress on the radius and increased load
on the common extensor origin. This leads to medial
and inferior displacement of the radius head, which
results in the need to retrain supinator and extensor
carpi radialis brevis eccentrically. The restoration of
muscle conditioning is best effected through pro-
gressive resisted exercise programmes for the upper
limb muscles and particularly concentrating on the
extensors of the wrist and hand.[68]
The successful management and outcome of case
studies associated with lateral epicondylosis* have
been reported in golf.[38] Several studies have pro-
spectively examined the effects of strength training
on reducing elbow injury. Lachowetz et al.[109] ex-
amined the effect of an 8-week upper-body,
strength-training programme on shoulder and elbow
pain levels (using a 10cm visual analogue scale) in
19 intercollegiate baseball players (11 training, 8
control, aged 18–22 years) 24, 48 and 72 hours
following a maximal throwing session. There were
significant differences at all time intervals for mean
shoulder pain, but no significant differences for
elbow pain levels.
Tyrdal and Pettersen[110] examined the effect of a
strength-training programme after 24 months in a
prospective uncontrolled clinical trial in 16 amateur
goalkeepers (25 injured elbows, 16 male and 9 fe-
male, mean age 21 years, elbow pain for 28.9
months) with handball goalie’s elbow. Concentric
and eccentric elbow exercise loads at approximately
80% of one repetition maximum were completed
8–10 times three times a day, 3 days a week. Muscle
strength after specific strength training improved for
flexion and extension of the elbow and wrist, and
pronation and supination of the forearm.
Svernlov and Adolfsson[111] investigated the use
of eccentric exercises in the treatment of lateral
epicondylalgia. A pilot study of 30 patients were
© 2006 Adis Data Information BV. All rights reserved.
163
allocated to one of two groups: a stretching group
and an eccentric group. The stretch group received
conservative treatment including contract relax ex-
ercises (15- to 20-second holds, 3–5 repetitions
twice daily for 12 weeks) while the eccentric group
performed eccentric lowering exercises using a
dumbbell, three sets of five repetitions as well as
stretches over a similar time frame. Measurements
of pain and grip strength were assessed after 12
weeks and then 41 months post-treatment. Results
of the pilot study demonstrated that 71% of the
eccentric group rated themselves as completely re-
covered compared with 39% in the stretch group.
Grip strength increased significantly in both groups
at 3 months but at 6 months the eccentric group was
significantly different. By 12 months there were no
significant differences.
On the basis of these results, a larger study[111]
was undertaken using 129 patients. These were fur-
ther subdivided into patients with lateral epicondy-
lalgia of <1 year’s duration and those with a dura-
tion of >1 year. The same protocol and outcome
measures were used as in the pilot study. In both
groups, pain had significantly reduced and grip
strength increased significantly at 3 months but by
12 months there were no significant differences
between the groups. The authors concluded that
including the eccentric programme reduced the
symptoms of lateral epicondylalgia and that the ec-
centric treatment was superior to stretching alone,
although this statement was not supported by the
results of the larger cohort only the pilot study.
It is recommended that throw training with
weights of >3kg should be avoided. This recommen-
dation is based on a study of long-term changes in
elbow joints of 21 former elite javelin throwers[112]
examined clinically and radiographically at an aver-
age of 19 years after the end of their high perform-
ance phase (mean age at examination was 50 years).
Three athletes complained about transient elbow
pain in their throwing arm affecting activities of
daily living; ten athletes had a deficit of extension of
>5°. All dominant elbows had advanced arthrotic
alterations (osteophytes, sclerosis) compared with
the non-dominant side. Athletes who trained with
weights of >3kg had a significantly higher risk of
degenerative changes in the elbow than athletes who
did not.
Sports Med 2006; 36 (2)
164
4.2.6 Operative Treatments
A minority of patients will have persistent
problems and require surgical intervention that can
reliably relieve pain and return patients to their
former level of activity.[43] The small percentage of
cases that require surgery usually benefit from de-
bridement of the damaged portion of the extensor
carpi radialis brevis attachment. The postoperative
course must include muscle strengthening and a
gradual return to activity.[27]
Lateral epicondylosis can almost always be treat-
ed non-operatively with activity modification and
specific exercises. Patients with medial or lateral
epicondylosis* not responding to an extensive non-
operative programme after 6 months to 1 year are
candidates for surgical intervention.[12] Surgical ap-
proaches to alleviate elbow pain have been de-
scribed for ulnar collateral reconstruction,[113] lateral
epicondylosis*[47] and medial epicondylosis*.[71]
Budoff and Nirschl[47] have reported symptomatic
improvement in 97% of lateral tennis elbow patients
surgically treated with excision of the pathological
tissue without release of adjacent motor units. Suc-
cessful surgery has been reported for five baseball
pitchers who could not continue to play at a compet-
itive level because of pain occurring between the
acceleration phase and follow-through phase.[114]
All five pitchers exhibited a significant osteophyte
on the posteromedial aspect of the olecranon pro-
cess, which when removed by surgery allowed all
five pitchers to return to a level of maximum per-
formance with the original valgus extension over-
load in the pitching elbow reduced.
Elbow arthroscopy is a useful modality for loose
body and osteophyte removal, synovectomy, joint
contracture release, evaluation of undiagnosed el-
bow pain, evaluation and treatment of acute frac-
tures, diagnosis of ulnar collateral ligament tears[115]
and treatment of posterior olecranon impinge-
ment.[116] Elbow arthroscopy allows the treatment to
be conducted with minimal soft tissue dissection,
low morbidity, and a rapid return of the athlete to
competition.[115]
A randomised, double-blind, comparative pro-
spective trial of patients showed that the Nirschl
tennis elbow release with drilling conferred no bene-
fit and actually caused more pain, stiffness, and
wound bleeding than not drilling.[117] There was no
© 2006 Adis Data Information BV. All rights reserved.
Hume et al.
significant difference in patient satisfaction, grip
strength, pain or elbow function from the release of
the common extensor origin or release of the com-
mon extensor origin and drilling of the lateral
epicondyle in the management of recalcitrant tennis
elbow for 125 elbows.[72] Release of the common
extensor origin at the elbow is a relatively simple
operation, and produces reliable long-term relief of
tennis elbow pain in at least 70% of patients.
Ollivierre et al.[71] reported resection and repair
for 50 cases in 48 patients of intractable medial
tendinosis (medial humeral epicondylosis*). The in-
jured tendon was excised, while retaining and clos-
ing the resection defect. At surgery, the flexor carpi
radialis-pronator teres interval was involved in 28
cases. Histological examination revealed angi-
ofibroblastic tendinosis and fibrillary degeneration
of collagen. Ten patients did not return to their
sporting or occupational activities. A large percent-
age of patients who fail conservative treatment for
medial humeral epicondylosis* can obtain pain re-
lief and return to activities with the described opera-
tive technique.
Surgical management, when required for triceps
tendonosis, involves subperiosteal exposure and ex-
cision of the spur and the olecranon tip and formal
repair of the triceps tendon.[56] Arthroscopic elbow
debridement can often be helpful in improving mo-
tion and in reducing pain in patients with poster-
omedial olecranon impingement on the olecranon
fossa.[12]
4.3 Effectiveness of Injury
Management Protocols
The relative effectiveness of four treatment pro-
tocols (ultrasound and a home programme, ultra-
sound with 10% hydrocortisone and a home pro-
gramme, transcutaneous electrical nerve stimulation
and a home programme, and subcutaneous injection
with a corticosteroid and a home programme) on
lateral epicondylosis* of the elbow were compared
by assessing patient pain responses with a modified
McGill Pain Questionnaire.[89] A total of 48 subjects
(12 in each treatment category) all showed a de-
crease in mean pain intensity after the 5-day treat-
ment time, and all of the pain indexes showed some
statistical differences between pre-and post-treat-
ment values, indicating that all the treatments were
Sports Med 2006; 36 (2)
Epicondylar Injury in Sport
effective in reducing pain. However, the four treat-
ment protocols did not differ significantly in their
effectiveness, so the treatment of choice should be
based on clinical considerations.
Patients treated for lateral epicondylosis* in a
sports medicine clinic between 1978 and 1980 re-
ceived a brief questionnaire investigating the level
of success of a treatment regime for lateral epicon-
dylosis*.[118] The amount of pain prior to treatment
was the most important predictor of complete recov-
ery; the greater the pain the more likely the complete
success of the treatments.
Twenty-three subjects with lateral epicon-
dylosis* treated with Cyriax manipulative therapy,
ice and a tennis elbow band demonstrated signifi-
cant improvement in pain, ROM and function of the
affected arm compared with a control group of 15
subjects with lateral epicondylosis* who received
only physiotherapy.[119]
A systematic review was undertaken by
Smidt[120] looking at the effectiveness of physical
therapy interventions for tennis elbow. Twenty-
three studies (nine laser, eight ultrasound, four elec-
trotherapy and five mobilisation and exercise) were
identified. All studies were considered to have poor
methodological quality and were not able to detect a
medium effect size. Based on weak evidence, it
seems that ultrasound was slightly better than place-
bo in its effect.
Smidt[120] also conducted a randomised, con-
trolled trial to investigate the effects of cortisone
versus physical therapy (deep friction massage/ul-
trasound/exercises) versus wait and see (ergonomic
advice/pain relief). Of the 185 subjects recruited, 62
were placed in the cortisone group, 64 in the physi-
cal therapy group and 59 in the wait-and-see group.
Outcomes at 6, 12, 26, 52 weeks were general
improvement, severity of main complaint, pain, el-
bow disability and patient satisfaction. With respect
to patient satisfaction, at 6 weeks 92% of the cor-
tisone group said they were completely recovered
compared with 47% of the physical therapy group
and 32% of the wait-and-see group. By 12 weeks
there were no differences between any of the groups.
The conclusion of this study was that the approach
taken may depend on resources, i.e. cost. With re-
spect to 52 weeks of treatment cost (actual treatment
plus transport and work-related compensation; 2002
© 2006 Adis Data Information BV. All rights reserved.
165
values), cortisone ($NZ860) was cheaper than phys-
ical therapy ($NZ1800) or wait and see ($NZ1260).
However other than cost there must be consideration
of effects of cortisone on type 1 collagen healing.
Extracorporeal shockwave therapy may be an
effective conservative treatment method for unilat-
eral chronic tennis elbow; however, the efficacy of
additional cervical manual therapy for lateral
epicondylosis* remains questionable. A prospec-
tive, matched, single-blind, controlled trial com-
pared low-energy extracorporeal shockwave therapy
and low-energy extracorporeal shockwave therapy
plus manual therapy of the cervical spine in treating
30 patients with chronic unilateral lateral epicon-
dylosis* of the elbow.[121] All patients had received
6 months of prior unsuccessful conservative therapy
and at the time of the trial showed clinical signs of
cervical dysfunction (pressure pain at the C4-5 and/
or C5-6 level and protraction of the head). Three
times at weekly intervals all patients received 1000
shockwave impulses of an energy flux density of
0.16 mJ/mm2 at the lateral elbow and manual ther-
apy of the cervical spine and the cervicothoracic
junction ten times. For each patient, an age- and sex-
matched control was drawn at random from 127
patients who had undergone low-energy shockwave
therapy in the same unit in the past 3 years. The
shockwave therapy showed significant improve-
ment in the outcome score (56% in the excellent or
good category: no or only occasional discomfort
without limitation of activity and ROM) compared
with pre-treatment outcomes at 12 months follow-
up, but the manual therapy did not improve the
outcome substantially more than the shockwave
therapy (60% in the excellent or good category).
The most effective modalities of treatment are
probably rest (the absence of painful activity) com-
bined with cryotherapy in the acute stage then
NSAIDs and heat in its various modalities including
ultrasound.[36] Cortisone injections may be used to
create a pain-free window of opportunity to optimise
the athletes rehabilitation exercises. Cortisone injec-
tions while being effective in some patients should
be limited to two injections at which stage other
diagnosis and interventions should be considered. In
1997, the Dutch College of General Practitioners[122]
developed a guideline for management of lateral
Sports Med 2006; 36 (2)
166
epicondylitis. Based on the lack of good quality
evidence they proposed a ‘wait-and-see’ approach.
5. Injury Prevention of Epicondylar Injury
Injury prevention in sport includes assessment of
the mechanism of injury with evaluation of the
effectiveness of intervention designed to prevent the
injury mechanisms. There are few studies on the
effectiveness of interventions to reduce the risk of
epicondylar injury. Rehabilitation requires attention
to strengthening of the muscles around the elbow
joint, gradual return to full play, and attention to the
biomechanics of the arm movement patterns. In
sports such as tennis, the stroke production, type,
weight and balance of racquet tension of strings and
size of grip should be considered.[36] Proper tech-
nique, conditioning and equipment are important in
reducing the risk of injury to the elbow.[5] Backhand
stroke mechanics in tennis have been identified as a
risk factor for elbow pain.[46] Strategies for avoiding
elbow pain in young pitchers[123] have been provid-
ed. Strengthening and stretching exercises and limits
on throwing activities have been suggested for pre-
vention of osteochondritis dissecans.[124] Prevention
also entails on- and off-season strengthening
programmes, proper warm-up and stretching exer-
cises, rehabilitation of previous injuries, and correc-
tion of improper mechanics.[32]
5.1 Training Volume, Intensity and Duration
Lyman et al.[125] conducted a two-season longitu-
dinal study of elbow complaints in 298 youth base-
ball pitchers to identify the associations between
pitch types, pitch volume, and other risk factors for
‘little league pitchers elbow’ conditions. Telephone
contact after each game pitched identified 26% el-
bow pain with risk factors of increased age, in-
creased weight, decreased height, lifting weights
during the season, playing baseball outside the
league, decreased self-satisfaction, arm fatigue dur-
ing the game pitched, and throwing <300 or >600
pitches during the season. Lyman et al.[125] suggest-
ed that young pitchers should not throw >75 pitches
in a game; pitchers should be removed from a game
if they demonstrate arm fatigue, and pitching in non-
league games should be limited. Congeni[32] has also
suggested that too much throwing is the major con-
© 2006 Adis Data Information BV. All rights reserved.
Hume et al.
tributing factor elbow injury, so prevention must
include limiting the number of pitches.
5.2 Biomechanics, Equipment
and Technique
Medial epicondylosis* in the throwing athlete is
typically a result of repetitive loading of the flexor/
pronator mass or because of acute overload of the
flexor/pronator mass. The mechanics in throwing
include elbow extension, forearm pronation, and
wrist palmar flexion in motion progressed from the
acceleration phase to the release phase. The active
contraction with forearm pronation and wrist palmar
flexion, combined with extension at the elbow, re-
sults in an eccentric load being applied to the flexor
pronator mass. The additional concern of valgus
stress being applied with the throwing mechanism
simply exacerbates this mechanical predisposition
to overload of the flexor pronator mass.[54]
Poorly adapted kinematics of the wrist and el-
bow, vibration produced when a ball hits the racqu-
et, and twisting forces induced by off-centre impacts
overstress the tendon. Some authors consider that
extensor muscle group being nearly at maximum
contraction, force is directly transmitted to the tendi-
nous insertion.[34]
Alterations in equipment and techniques that
contribute to tennis elbow are often key to recovery
and prevention.[29] A change of racquet and coach-
ing from a tennis professional can help reduce the
risk of injury.[28] Grip bands have little effect on
reducing racquet vibration but can improve resis-
tance against slipping.[34] The two-hand backstroke
is probably the best backhand stroke to prevent
lateral tennis elbow.[34] Alterations in equip-
ment[5,90,126] and techniques that contribute to the
elbow injury are often suggested as the key to recov-
ery and prevention;[29] however, there is very limited
information or guidelines for players in sports re-
garding how to choose appropriate equipment or
how to change technique to reduce the risk of elbow
injury. There are no prospective studies evaluating
different types of equipment and elbow injury risk.
The tennis elbow band, also known as a
counterforce brace, offers one method of decreasing
stress in patients diagnosed with tennis elbow.[127]
An elastic strap or an inelastic strap on the forearm
Sports Med 2006; 36 (2)
Epicondylar Injury in Sport
both produced an increased pain-free grip strength
compared with grip strengths measured without a
forearm strap for 85% of 27 players with tennis
elbow.[128] The effect of the lateral counterforce
armband on wrist extension and grip strength, and
pain was assessed with dynametric strength tests and
pain analogue scale assessments in 14 subjects with
tennis elbow.[129] The armband increased wrist ex-
tension and grip strength in both affected and unaf-
fected arms (the greatest effects were seen in the
affected arm). The armband doubled the increase in
wrist extension compared with grip strength for both
arms. There was a low negative correlation between
changes in pain and strength, but it was not statisti-
cally significant.[129] However, use of the tennis
elbow strap for elbow growth plate problems in
children and adolescents or medial elbow instability
in adults may actually exacerbate those condi-
tions.[127] Counterforce bracing is typically unsuc-
cessful for triceps tendonitis because the cross-sec-
tion of the arm changes with biceps contraction.[56]
Certain kinematic and electromyographic charac-
teristics in backhand strokes have been implicated as
major factors responsible for lateral elbow pain.
Enomoto[35] conducted kinematic and electromy-
ographic analysis of backhand strokes in tennis
players with and without lateral elbow pain. Twen-
ty-two intermediate to advanced skill-level recrea-
tional players were divided into four groups (one-
handed and two-handed technique with and without
lateral elbow pain) and were analysed in terms of
three-dimensional kinematic and electromyographic
characteristics of backhand strokes. Players who
used the one-handed technique had significantly
larger joint angular displacements and had a greater
risk of lateral elbow pain because of an unstable
joint angle (loose packed position) at impact.
Gerber[46] interviewed, clinically examined and
photographically observed playing technique during
training and competition for 46 world-class tennis
players. The forehand playing technique was related
to the development of ulnar epicondylalgia, with a
particular backhand technique associated with radial
epicondylalgia. Twelve amateur players were also
observed with stroke changes resulting in the cure
for eight players and pain reduction for the other
four players. Gerber suggested that clinical and
more sophisticated biomechanical studies should be
© 2006 Adis Data Information BV. All rights reserved.
167
conducted to establish the relationship between par-
ticular stroke techniques and the development of
epicondylalgia.
There is a significant association between the
number of pitches thrown in a game and during a
season and the rate of elbow pain and shoulder pain
in youth baseball pitchers.[130] Youth pitchers should
be cautioned about throwing breaking pitches
(curveballs and sliders) because of the increased risk
of elbow and shoulder pain. Limitations on pitches
thrown in a game and in a season should reduce the
risk of pain. These recommendations come from a
study[130] of 467 young (aged 9–14 years) baseball
pitchers followed for one season. Data were collect-
ed from pre- and postseason questionnaires, injury
and performance interviews after each game, pitch
count logs and video analysis of pitching mechanics.
Half of the pitchers experienced elbow or shoulder
pain during the season. The curveball was associat-
ed with a 52% increased risk of shoulder pain and
the slider was associated with an 86% increased risk
of elbow pain.
Priest et al.[15,16] analysed the elbows of tennis
players with and without pain and Qu et al.[131]
compared elbow angles during vaulting manoeuvres
in gymnasts with and without chronic elbow pain.
Further studies of technique for players with and
without pain are required in a variety of sports that
are at risk of epicondylar injury.
6. Conclusions
Epicondylar injuries are frequent in sports in-
volving overhead arm motions. Lateral and medial
epicondylosis are the most frequent and result from
acute and repetitive stressful mechanisms. Entrap-
ment neuropathies in the elbow or wrist are a non-
traumatic cause of pain and often present as in-
creased neural tension around the elbow on clinical
testing. Assessment should include a detailed histo-
ry, clinical examination and diagnostic tests if ap-
propriate. Conservative treatments such as cryother-
apy in the acute stage then NSAIDs are available for
lateral and medial epicondylosis; however, the ef-
fectiveness of rehabilitation protocols is largely still
controversial. There is very limited prospective
clinical or experimental evidence for the effective-
ness of injury prevention strategies to reduce the risk
of epicondylar injury. More emphasis needs to be
Sports Med 2006; 36 (2)
168
placed on prevention of elbow injury in sport by
medical and sport-science personnel working with
coaches and athletes to improve joint strength, ROM
and sport technique.
Acknowledgements
The Institute of Sport and Recreation New Zealand, AUT,
funded this study. The authors have no conflicts of interest
directly relevant to the content of this review.
References
1. Murley AH. Painful elbow. Practitioner 1985; 2 (5): 36-41
2. Servi JT, Johnson RJ. A swollen, painful elbow. Phys Sport-
smed 1996; 24 (9): 49-51
3. Regan WD. Lateral elbow pain in the athlete: a clinical review.
Clin J Sport Med 1991; 1 (1): 53-8
4. Gailey RK, Andrews JR, Whiteside JA. Medial elbow pain in a
ninth grade pitcher. 3rd ed. Rancho Mirage (CA): American
Medical Society for Sports Medicine, 1994
5. Field LD, Altchek DW. Elbow injuries. Clin Sports Med 1995;
14 (1): 59-78
6. Mallon B. How to cure and prevent golfer’s elbow: knowing the
cause can help you avoid playing in pain. Golf Digest 1998; 49
(3): 119-21
7. Herzog RJ. Magnetic resonance imaging of the elbow. Oper
Tech Sports Med 1997; 5 (1): 19-32
8. Kraushaar BS, Nirschl RP. Tendinosis of the elbow: clinical
features and findings of histological, immunohistochemical,
and electron microscopy studies. J Bone Joint Surg 1999; 81
(2): 259-78
9. Demarais Y, Parier J, Poux D. Les douleurs du compartiment
externe du coude: essai de demembrement. J Traumatol Sport
1998; 15 Suppl. 1: 5
10. Brukner P, Khan K, Bell S. Elbow and forearm pain. In: Brukner
P, editor. Clinical sports medicine. 2nd ed. Sydney: McGraw
Hill, 2002: 274-91
11. Rettig AC, Patel DV. Epidemiology of elbow, forearm, and
wrist injuries in the athlete. Clin Sports Med 1995; 14 (2):
289-97
12. Field LD, Savoie FH. Common elbow injuries in sport. Sports
Med 1998; 26 (3): 193-205
13. Patmore A. Pain in the arm. Tennis World 1980; 11 (9): 38-9
14. Renstroem PAFH. Elbow injuries in tennis. In: Reilly T, Hughes
M, Lees M. First World Congress of Science and Racket
Sports; 1993 Jul 9-13; Runcorn (Cheshire). London: E & FN
Spon, 1995
15. Priest JD, Braden V, Gerberich SG. Elbow and tennis. Part 1: an
analysis of players with and without pain. Phys Sportsmed
1980; 8 (4): 80-4
16. Priest JD, Braden V, Gerberich SG. Elbow and tennis. Part 2:
study of players with pain. Phys Sportsmed 1980; 8 (5): 77-80
17. Davenport K. Elbow pain. Wind Surf 1986; 16 (11): 14
18. Haas JC, Meyers MC. Rock climbing injuries. Sports Med
1995; 20 (3): 199-205
19. Josefsson PO, Gentz CF, Pettersson H, et al. Arthrography in
javelin throwers with medial elbow pain. Scand J Med Sci
Sports 1994; 4 (4): 252-5
20. Tyrdal S, Bahr R. High prevalence of elbow problems among
goalkeepers in European team handball: ‘handball goalie’s
elbow’. Scand J Med Sci Sports 1996; 6 (5): 297-302
21. Shuster DB, Britell CW. Disabling pain and injury in road racers
who use wheelchairs. In: Tenenbaum G, editor. Coach educa-
tion: proceedings of the Maccabiah-Wingate International
© 2006 Adis Data Information BV. All rights reserved.
Hume et al.
Congress; 1991; Netanya. Netanya: The Emmanuel Gill Pub-
lishing House, Wingate Institute for Physical Education and
Sport, 1991: 103-13
22. Bell MM. Elbow pain in a cyclist. Phys Sportsmed 1997; 25 (5):
83-4
23. Scott C. Elbow pain in the weight lifter. Int Olympic Lifter
1976; 3 (4): 7
24. Sol G, Fornaris E, Vanuxem P, et al. Halterophilie. Med Sport
1987; 61 (5): 256-8
25. Lovell ME, Thomas AF. Upper limb function in the wheelchair
athlete. Sports Exerc Injury 1995; 1 (4): 198-200
26. Kurppa K, Waris P, Rokkanen P. Tennis elbow: lateral elbow
pain syndrome. Scand J Work Environ Health 1979; 5 (3):
15-8
27. Leach RE, Miller JK. Lateral and medial epicondylitis of the
elbow. Clin Sports Med 1987; 6 (2): 259-72
28. Kamien M. Tennis elbow in long-time tennis players. Aust J Sci
Med Sport 1988; 20 (2): 19-27
29. Harvey J, Glick J, Stanish W, et al. Tennis elbow: what’s the
best treatment? Phys Sportsmed 1990; 18 (6): 62-4
30. Nocini S, Silvij S. Clinical and radiological aspects of gym-
nast’s elbow. Note 2. J Sports Med Phy Fitness 1982; 22 (1):
54-9
31. Micheli LJ. Elbow pain in a little league pitcher. In: Smith NJ,
editor. Common problems in pediatric sports medicine. Chica-
go (IL): Year Book Medical Publishers, 1989: 233-41
32. Congeni J. Treating and preventing Little League elbow. Phys
Sportsmed 1994; 22 (3): 54-5
33. Tyrdal S, Finnanger AMS. Osseous manifestations of ‘handball
goalie’s elbow’. Scand J Med Sci Sports 1999; 9 (2): 92-7
34. Fichez O. Epicondylite: histoire naturelle et etude critique des
differents traitements. J Traumatol Sport 1998; 15 (3): 163-72
35. Enomoto K. Kinematic and electromyographic analysis of back-
hand strokes in tennis players with and without lateral elbow
pain [dissertation]. Eugene (OR): University of Oregon, 1997
36. Kamien M. A rational management of tennis elbow. Sports Med
1990; 9 (3): 173-91
37. Schickendantz M. Diagnosis and treatment of elbow disorders
in the overhead athlete. Hand Clin 2002; 18 (1): 65-75
38. Grimshaw P, Giles A, Tong R, et al. Lower back and elbow
injuries in golf. Sports Med 2002; 32 (10): 655-66
39. Nirschl RP, Kraushaar BS. Assessment and treatment guidelines
for elbow injuries. Phys Sportsmed 1996; 24 (5): 42-4
40. Tian D, Qu M. Rupture of ligaments and muscles on the ulnar
side following instability of the medial side of the elbow in
athletes (an analysis of 33 cases) [in Chinese]. Chinese J Sports
Med 1987; 6 (3): 134-8
41. Wojtys EM, Smith PA, Hankin FM. A cause of ulnar neuropa-
thy in a baseball pitcher: a case report. Am J Sports Med 1986;
14 (5): 422-4
42. Pienimaeki T, Tarvainen T, Siira P, et al. Associations between
pain, grip strength, and manual tests in the treatment evalua-
tion of chronic tennis elbow. Clin J Pain 2002; 18 (3): 164-70
43. Ciccotti MG, Charlton WPH. Epicondylitis in the athlete. Clin
Sports Med 2001; 20 (1): 77-93
44. Pienimaki TT, Siira PT, Vanharanta H. Chronic medial and
lateral epicondylitis: a comparison of pain, disability, and
function. Arch Phys Med Rehabil 2002; 83 (3): 317-21
45. Jeffries T. Lateral elbow pain. Perth (WA): Australian Physio-
therapy Association, 1996: 9-10
46. Gerber C. Tennisellbogen. Ein anderes aetiologisch-ther-
apeutisches Konzept. Schweiz Z Sportmed 1987; 35 (1): 13-9
47. Budoff JE, Nirschl RP. Resection and repair of lateral tennis
elbow. Oper Tech Sports Med 2001; 9 (4): 211-6
48. Derkash RS. Posterior interosseous nerve injuries in the athlete.
Oper Tech Sports Med 1996; 4 (1): 28-32
Sports Med 2006; 36 (2)
Epicondylar Injury in Sport
49. Green S, Buchbinder R, Barnsley L, et al. Non-steroidal anti-
inflammatory drugs (NSAIDs) for treating lateral elbow pain
in adults. Cochrane Database Systematic Review 2002; 2:
CD003686
50. Yaxley G, Jull G. Adverse tension in the neural system: a
preliminary study in patients with tennis elbow. Aust J Physi-
other 1993; 39: 15-22
51. Jobe F, Hamner D, Pink M. Mini symposium: elbow problems:
overuse injuries of the elbow. Curr Orthop 1997; 11: 249-54
52. Connell D, Burke F, Coombes P, et al. Sonographic examination
of lateral of lateral epicondylitis. Am J Roentgenol 2001; 176
(3): 777-82
53. Nirschl RP. Prevention and treatment of elbow and shoulder
injuries in the tennis player. Clin Sports Med 1988; 7 (2):
289-308
54. Gabel GT. Management of medial epicondylitis in the throwing
athlete. Oper Tech Sports Med 2001; 9 (4): 205-10
55. Kerger S, Brolinson G. Differential of medial elbow pain in the
athlete. Sports Med Alert 2000; 6 (4): 29-31
56. Jafarnia K, Gabel GT, Morrey BF. Triceps tendinitis. Oper Tech
Sports Med 2001; 9 (4): 217-21
57. Khan K, Maffulli N. Patellar tendinopathy: some aspects of
basic science and clinical management. Br J Sports Med 1998;
32: 346-55
58. Bernstein AD, Breslow MJ, Jazrawi LM. Distal biceps tendon
ruptures: a historical perspective and current concepts. Am J
Orthop 2001; 30 (3): 193-200
59. Safran MR, Graham SM. Distal biceps tendon ruptures: inci-
dence, demographics, and the effect of smoking. Clin Orthop
Relat Res 2002 Nov; (404): 275-83
60. Williams JS, Hang DW, Bach BR. Distal biceps rupture in a
snowboarder: case report. Phys Sportsmed 1996; 24 (12):
66-70
61. Nukada H, Gerrard DF. Peripheral neuropathy in sport and
recreation 1: radial, median and ulnar nerves. N Z J Sports Med
1991; 19 (3): 53-6
62. Posner MA. Compressive neuropathies of the median and radial
nerves at the elbow. Clin Sports Med 1990; 9 (2): 343-63
63. Burnham RS, Steadward RD. Upper extremity peripheral nerve
entrapments among wheelchair athletes: prevalence, location,
and risk factors. Arch Phys Med Rehabil 1994; 75 (5): 519-24
64. Moskal MJ. Arthroscopic treatment of posterior impingement of
the elbow in athletes. Clin Sports Med 2001; 20 (1): 11-24
65. Herrick RT. Radial tunnel syndrome: a cause of chronic lateral
elbow pain. Chiropractic Sports Med 1992; 6 (1): 21-4
66. Lutz FR. Radial tunnel syndrome: an etiology of chronic lateral
elbow pain. J Orthop Sports Phys Ther 1991; 14 (1): 14-7
67. Allen DM, Nunley JA. Lateral antebrachial cutaneous neuropa-
thy. Oper Tech Sports Med 2001; 9 (4): 222-4
68. Vicenzino B. Lateral epicondylalgia: a musculoskeletal physio-
therapy perspective. Man Ther 2003; 8 (2): 66-79
69. Timmerman LA, Andrews JR. Undersurface tear of the ulnar
collateral ligament in baseball players: a newly recognized
lesion. Am J Sports Med 1994; 21 (1): 33-6
70. Benjamin SJ, Willimas DA, Kalbfleisch JH, et al. Normalized
forces and active range of motion in unilateral radial epicondy-
lalgia (tennis elbow). J Orthop Sports Phys Ther 1999; 29 (11):
668-76
71. Ollivierre CO, Nirschi RP, Pettrone FA. Resection and repair
for medial tennis elbow: a prospective analysis. Am J Sports
Med 1995; 23 (2): 214-21
72. Das D, Maffulli N. Surgical management of tennis elbow. J
Sports Med Phy Fitness 2002; 42 (2): 190-7
73. Timmerman LA, Andrews JR. Arthroscopic treatment of post-
traumatic elbow pain and stiffness. Am J Sports Med 1994; 22
(2): 230-5
© 2006 Adis Data Information BV. All rights reserved.
169
74. Salvo JP, Rizio-Iii L, Zvijac JE, et al. Avulsion fracture of the
ulnar sublime tubercle in overhead throwing athletes. Am J
Sports Med 2002; 30 (3): 426-31
75. Smith RW, Mani R, Cawley MID, et al. Assessment of tennis
elbow using the Marcy Wedge-Pro. Br J Sports Med 1993; 27
(4): 233-6
76. Stratford PW, Norman GR, McIntosh JM. Generalizability of
grip strength measurements in patients with tennis elbow. Phys
Ther 1989; 68 (4): 276-81
77. Fritz RC, Brody GA. MR imaging of the wrist and elbow. Clin
Sports Med 1995; 14 (2): 315-52
78. Schickendantz MS, Ho CP, Koh J. Stress injury of the proximal
ulna in professional baseball players. Am J Sports Med 2002;
30 (5): 737-41
79. Timmerman LA, Schwartz ML, Andrews JR. Preoperative eval-
uation of the ulnar collateral ligament by magnetic resonance
imaging and computed tomography arthrography: evaluation
in 25 baseball players with surgical confirmation. Am J Sports
Med 1994; 21 (1): 26-32
80. Wilson A. Effective management of musculoskeletal injury: a
clinical ergonomics approach to prevention, treatment, and
rehabilitation. Edinburgh: Churchill Livingstone, 2002
81. Ralston BM, Williams JS, Bach BR, et al. Osteochondritis
dissecans of the knee. Phys Sportsmed 1996; 24 (6): 73-80
82. Hunter G. Specific soft tissue mobilisation in the management
of soft tissue dysfunction. Man Ther 1998; 3 (2): 2-11
83. Hume PA, Potts G. SportSmart: the 10-point plan for sports
injury prevention: an educational resource. 1st ed. Wellington:
Accident, Rehabilitation and Compensation Insurance Corpo-
ration of New Zealand, 1999
84. Jenoure PJ, Rostan A, Gremion G, et al. Studio multicentrico
controllato in doppio cieco su diclofenac Tissugel plaster in
pazienti con epicondilite. Med Sport (Roma) 1997; 50 (3):
285-92
85. Akermark C, Crone H, Elsasser U, et al. Glycosaminoglycan
polysulfate injections in lateral humeral epicondylalgia: a pla-
cebo-controlled double-blind trial. Int J Sports Med 1995; 16
(3): 196-200
86. Baer C, Bias P, Rose P. Dexamethasonpalmitat bei akuter
Epikondylitis humeri radialis. Dtsche Z Sportmed 1997; 48
(3): 119-20
87. Wiggins M, Fadale P, Barrach H, et al. Healing characteristics
of a type 1 collagenous structure treated with corticosteroids.
Am J Sports Med 1992; 22 (2): 279-88
88. Blackard D, Sampson JA. Management of an uncomplicated
posterior elbow dislocation. J Athl Train 1997; 32 (1): 63-7
89. Halle JS, Franklin RJ, Karalfa BL. Comparison of four treat-
ment approaches for lateral epicondylitis of the elbow. J
Orthop Sports Phys Ther 1986; 8 (2): 62-9
90. Nirschl RP, Sohel J. Conservative treatment of tennis elbow.
Phys Sportsmed 1981; 9 (6): 42-8
91. Bond K. Treatment of elbow pain using myofascial techniques.
Perth (WA): Australian Physiotherapy Association, 1996: 12-3
92. Vines E. Myofascial approach to tennis elbow. Perth (WA):
Australian Physiotherapy Association, 1993
93. Souvlis T, Pearce L, Jull G, Wright A. Later analgesic effects of
spinal manual therapy on chronic ‘tennis elbow’ [abstract]. In:
Sports Medicine Australia, book of abstracts: 2000 Pre-
Olympic Congress. International Congress on Sport Science,
Sports Medicine and Physical Education; 2000 Sep 7-12;
Brisbane. Brisbane (QLD): Sports Medicine Australia, 2000
[online]. Available from URL: http://www.ausport.gov.au/
fulltext/2000/preoly/abs173b.htm [Accessed 2005 Sep 29]
94. Mulligan B. Manual therapy ‘NAGS’‘SNAGS’ and ‘MWM’s’.
4th ed. Wellington: Planeview Services Ltd, 1999
Sports Med 2006; 36 (2)
170
95. Vicenzino B, Wright A. Effects of a novel manipulative physio-
therapy technique on tennis elbow: a single case study. Man
Ther 1995; 1 (1): 30-5
96. Vicenzino B, Paungmali A, Buratowski S, et al. Specific manip-
ulative therapy treatment for chronic lateral epicondylagia
produces uniquely characteristic hypoalgesia. Man Ther 2001;
6 (4): 205-12
97. Abbott JH, Patla CE, Jensen RH. The initial effects of an elbow
mobilization with movement technique on grip strength in
subjects with lateral epicondylalgia. Man Ther 2001; 6 (3):
163-9
98. Vaughn B, Miller K, Fink D. Massage for sports health care.
Champaign (IL): Human Kinetics, 1998
99. Weerapong P, Hume PA, Kolt G. The mechanisms of massage
and benefits on performance and the severity of muscle dam-
age. Sports Med 2005; 35 (3): 235-56
100. Weerapong P, Hume PA, Kolt G. Preventative strategies for
exercise-induced muscle damage. Crit Rev Phys Rehabil Med
2004; 16 (2): 133-50
101. Gremion G, Augros R, Gobelet C, et al. Efficacite de la therapie
par ondes de choc extra-corporelles dans les tendinopathies
rebelles. J Traumatol Sport 1999; 16 (2): 117-21
102. Wang CJ, Chen HS. Shock wave therapy for patients with
lateral epicondylitis of the elbow: a one- to two-year follow-up
study. Am J Sports Med 2002; 30 (3): 422-5
103. Dreyfuss P, Stratton S, Herring SA. The low-energy laser,
electro-acuscope, and neuroprobe: treatment options remain
controversial. Phys Sportsmed 1993; 21 (8): 47-50
104. Basford JR, Sheffield CG, Cieslak KR. Laser therapy ineffec-
tive for lateral epicondylitis. Phys Sportsmed 2001; 29 (12): 1
105. Braun A, Stein W. Indikation zur Akupunktur bei der
Epikondylopathie. Orthopaed Praxis 1980; 16 (10): 891-4
106. Escribano A, Berral FJ, Delgado C, et al. Apports au traitement
de la pathologie douloureuse du denomme ‘coude du joueur de
tennis’. Med Sport (Paris) 1996; 70 (1): 9-16
107. Alfredson H, Pietila T, Jonsson P, et al. Heavy-Load eccentric
calf muscle training for the treatment of chronic Achilles
tendinosis. Am J Sports Med 1998; 26 (3): 360-6
108. Cook J, Khan K, Maffulli N, et al. Overuse tendinosis, not
tendinitis. Part 2: applying the new approach to patellar
tendopathy. Phys Sportsmed 2000; 28 (6): 31-46
109. Lachowetz T, Drury D, Elliot R, et al. The effect of an intercol-
legiate baseball strength program on the reduction of shoulder
and elbow pain. J Strength Cond Res 1998; 12 (1): 46-51
110. Tyrdal S, Pettersen OJ. The effect of strength training on ‘hand-
ball goalie’s elbow’: a prospective uncontrolled clinical trial.
Scand J Med Sci Sports 1998; 8 (1): 33-41
111. Svernlov B, Adolfsson L. Non operative treatment regime in-
cluding eccentric training for lateral humeral epicondylalgia.
Scand J Med Sci Sports 2001; 11: 328-34
112. Schmitt H, Hansmann HJ, Brocai DRC, et al. Long term
changes of the throwing arm of former elite javelin throwers.
Int J Sports Med 2001; 22 (4): 275-9
113. Azar FM. UCL reconstruction: a surgical approach to alleviate
elbow pain. Sports Med Update (Birmingham, Ala) 1997; 12
(3): 17-20
114. Wilson FD, Andrews JR, Blackburn TA, et al. Valgus extension
overload in the pitching elbow. Am J Sports Med 1983; 11 (2):
83-8
© 2006 Adis Data Information BV. All rights reserved.
Hume et al.
115. Martin SD, Baumgarten TE. Elbow arthroscopy in sports
medicine. Sports Med Arthroscopy Rev 1995; 3 (3): 187-94
116. Hepler MD, Manifold SG. Elbow arthroscopy in the treatment
of posterior olecranon impingement [abstract]. Medscape
Orthopaed Sports Med 1998 Mar/Apr; 2 (2)
117. Khashaba A. Nirschl tennis elbow release with or without
drilling. Br J Sports Med 2001; 35 (3): 200-1
118. Gerberich SG, Priest JD. Treatment for lateral epicondylitis:
variables related to recovery. Br J Sports Med 1985; 19 (4):
224-7
119. Baltaci G, Ergun N, Bayrakci-Tunay V. Effectiveness of Cyriax
manipulative therapy and elbow band in the treatment of
lateral epicondylitis. Eur J Sports Traumatol Relat Res 2002;
23 (3): 113-8
120. Smidt N. Conservative treatments for lateral epicondylitis in
primary care. Dutch J Phys Ther 2003; 113: S7-11
121. Rompe JD, Riedel C, Fink C. Chronic lateral epicondylitis of the
elbow: a prospective study of low-energy shockwave therapy
and low-energy shockwave therapy plus manual therapy of the
cervical spine. Arch Phys Med Rehabil 2001; 82 (4): 578-82
122. Assendelft WJ, Rikken SA, Mel M, et al. NHG practice guide-
line for epicondylitis [in Dutch]. Huisarts Wet 1997; 40: 21-6
123. Ciccantelli P. Avoiding elbow pain: tips for young pitchers.
Phys Sportsmed 1994; 22 (3): 65-6
124. Hall TL, Galea AM. Osteochondritis dissecans of the elbow:
diagnosis, treatment, and prevention. Phys Sportsmed 1999; 27
(2): 75-7
125. Lyman S, Fleisig GS, Waterbor JW, et al. Longitudinal study of
elbow and shoulder pain in youth baseball pitchers. Med Sci
Sports Exerc 2001; 33 (11): 1803-10
126. Miyasaka KC, Rosenwasser MP. Diagnostic wrist arthroscopy.
Oper Tech Sports Med 1998; 6 (1): 42-51
127. Harding WG. Use and misuse of the tennis elbow strap. Phys
Sportsmed 1992; 20 (8): 65-8
128. Burton AK. Annotation: grip strength and forearm straps in
tennis elbow. Br J Sports Med 1985; 19 (1): 37-8
129. Wadsworth CT, Nielsen DH, Burns LT, et al. Effect of the
counterforce armband on wrist extension and grip strength and
pain in subjects with tennis elbow. J Orthop Sports Phys Ther
1989; 11 (5): 192-7
130. Lyman S, Fleisig GS, Andrews JR, et al. Effect of pitch type,
pitch count, and pitching mechanics on risk of elbow and
shoulder pain in youth baseball pitchers. Am J Sports Med
2002; 30 (4): 463-8
131. Qu Y, Liu P, Li GP. Comparison of elbow angles in gymnasts
with and without chronic elbow pain in horse vault routine. In:
Hong Y, editor. Proceedings of XVIII International Symposi-
um on Biomechanics in Sports. Hong Kong: Department of
Sports Science and Physical Education; 2000 Jun 25-30; Hong
Kong. Hong Kong: The Chinese University of Hong Kong,
2000: 979
Correspondence and offprints: Assoc. Prof. Patria A. Hume,
Institute of Sport and Recreation New Zealand, Auckland
University of Technology, Private Bag 92006, Auckland,
New Zealand.
E-mail: patria.hume@aut.ac.nz
Sports Med 2006; 36 (2)