Test your Tennis Medicine Knowledge - Case Study

Clinical Case:

A 16 y/o left handed female high school tennis athlete presents to your outpatient medical clinic reporting a 0-5/10 pain over the left inner elbow which began two weeks ago without change in stroke technique or volume of play. She

denies previous history of the same or acute injury. The pain is worse with tennis play and better with rest. She denies radiating neck pain or numbness/tingling into the forearm or hand. Further questioning determines:

Volume of play: 4 times per week, an average of 2 hrs per time, for the last 3 years

Type of play: 1 match per week, 2 academy sessions per week and 1 private

lesson

Forehand Grip Type: Athlete is unsure of this

Raquet Variables: 100 square inch frame, 4 1/2 in grip size, 16g monofilament synthetic gut strung at 52lbs

PMH: None

PSH: Left Shoulder Labral Repair 2017

Clinical Algorithm:

BACKGROUND

Pain over the elbow is one of the leading complaints of the recreational tennis athlete. Lateral Elbow pain is most common and frequently related to the Extensor Carpi Radialis Brevis tendon at it’s insertion on the lateral epicondyle. Also included in the differential for lateral elbow pain are a C6 Radiculitis, a

Posterior Interosseous Neuropathy and acute bony or soft tissue trauma.

Although medial elbow pain is less common, it is frequently experienced

by the tennis athlete. Determining the source of pain and inciting and alleviating factors and a “tennis medicine” based plan of care is essential to a successful

outcome.

EVALUATION

On Physical Exam the following was identified:

• General: NAD, pleasant, conversational, interactive
  

• HEENT: Moist pink mucosa, pupils are equal, wearing contact lenses
  

• CV: Warm distal UE and 2+ radial pulses bilaterally with regular rate
  

• Neuro: 5/5 strength in the bilateral C5-T1 Myotomes, Normal sensation to light touch in the bilateral C5-T1 dermatomes, 2+ triceps, brachioradialis and biceps reflexes
  

• Provocative Tests: Negative Tinel’s at the elbow, Negative “milking test” and Valgus stress test
  

• Palpation: Mild tenderness over the proximal flexor tendon at it’s insertion to the epicondyle

DIFFERENTIAL DIAGNOSIS FOR ME DIAL ELBOW PAIN

Bones/Cartilage: Fracture, Inflammatory Arthritis, Osteochondral defect, Osteoarthrits, Avascular Necrosis, Medial Epicondylar Apophysitis

Tendon/Muscle/Ligament: Medial Epicondylitis, Flexor Tendon Tear, Triceps

Tendonitis/Tear, Distal Biceps tendon Injury, Brachialis Strain/tear, UCL Injury

Nerve: Ulnar Neuritis,Subluxating ulnar nerve, Median Nerve Entrapment

TREATMENT (THERAPEUTIC, PHARMACOLOGIC, SURGICAL)

Although the diagnosis for medial elbow pain is myriad, the diagnosis and treatment of the patient had little in this case to do with orthopedic diagnosis. As we discussed her pain and her efforts to date, I asked her a key question. “ Can

you show me what you think is the ideal groundstroke forehand contact point

for you?” She fumbled around a bit and tried multiple locations. Each was

different and all were “late” in reference to her body. As we discussed it

further, she admitted she did not know exactly where she should be hitting the

ball in reference to her body. She also commented that whenever she played against a “bigger and stronger” hitter her arm would hurt and when she played

against a weaker player she had minimal to no pain. That little tidbit turned out

to be what fixed the athlete. It wasn’t the X-rays I ordered which were normal

or the MSK ultrasound I performed that showed some mild hypo echoic

signal around the medial flexor tendon supportive of tendinosis. It wasn’t the

medications or the stretching program that would fix her. It was her on court

and tennis specific technical errors that were contributing to her presenting pain. She didn’t know the type of forehand grip she should be using nor where to even strike the ball in reference to the body. She needed me to rule out a few dangerous diagnosis, but she needed an excellent tennis professional to help modify her contact point to result in an earlier and a more consistent contact

point. Once this was adjusted her medial elbow pain resolved completely and has

not recurred.

EXPECTED OUTCOMES BASED ONTHE LITERATURE OR ANECDOTE

The literature suggests that medial epicondylitis will commonly resolve with

time and with rest. Anecdotally it will also improve with stroke modification and normalization of the force/tendon relationship on the forehand side. Once we confirmed an Eastern Grip type and worked on early rapid preparation, early

core rotation and contact of the ball “ on the rise” her pain improved significantly.

PREVENTION

The key to successful prevention is identifying technical flaws and fixing them

immediately.

Key Takeaways

1. With all tennis players consider the anatomic diagnosis and sports specific risk factors

2. If no acute surgical intervention is needed, trial sports specific management techniques immediately in conjunction with classic tenets of avoidance of pain provoking behaviors and a reduction in inflammation and acute pain.

3. Review the basics of each stroke to understand the primary risks of injury and faulty technique that places the athlete at increased risk of injury.