Tennis Elbow Tendinitis and Tennis Elbow Tendonitis – What is the Difference?

Tendinitis or Tendonitis are alternative spellings of the same condition. The -itis part means inflammation so the term tendonitis means inflammation of a tendon.
In medicine and medical textbooks you are more likely to see Tendinitis than Tendonitis although they are interchangeable.
However in Tennis Elbow Tendinitis there is generally no inflammation present and the more correct term is Tendinosis or Tendinopathy!

Tennis Elbow Tendonitis / Tendinitis Causes

Changes in the tendon are caused by repetitive movements or overuse of the muscle and tendon unit. Any activity that involves forceful gripping and / or quick repeated movements of the hand can lead to these changes and Tennis Elbow Tendonitis injuries and symptoms.

As I explained in Tennis Elbow Injury and Tennis Elbow Symptoms Tennis Elbow Tendonitis or Lateral Epicondylitis is pain in the outer aspect of your elbow and forearm and is generally not inflammatory but consists of degenerative changes in the structure of the Extensor Carpi Radialis Brevis (ECRB) or “Tennis Elbow Tendon.”

Taking part in a new activity which uses your arm, or doing more than usual of an activity can cause Tennis Elbow arm pain. Common examples are:

• tennis and racquet sports
• painting and decorating
• using handtools – saw, screwdriver, hammer etc
• using powertools – drills, sanders etc
• using a keyboard or mouse
• watersports involving gripping – waterskiing, sailboarding etc
• prolonged intricate movements of the hand – sewing, scissors, using a knife etc
• playing with the Wii games console too long

Wrist Extension Causes Tennis Elbow Injury

If I stick with tennis for the moment. Between 40 and 50% of all tennis players have experienced Tennis Elbow Tendonitis pain at least once, and for many it can persist for a long time and affect their participation in their sport.
Gripping any object involves extending the wrist (see picture above).
Resisting movements that cause the wrist to flex away from this extended position produce stress in the muscle and tendon and cause arm pain.
The classic example is a single-handed backhand in tennis – look at the forces involved in trying to ‘break’ the wrist in this picture.
These forces depend on various factors such as ball speed, speed of the racket, racket size, string stiffness, off-center impact and hand grip force.
Eccentric contraction forces in ECRB at ball impact are increased by bending the wrist and having low muscle activation.
This is exactly what is found in novice tennis players who are more prone to Tennis Elbow Tendonitis probably due to poor technique (and incorrect muscle activation) with the backhand and service strokes. It is this lack of correct muscle activation that results in increased force transmission to the ECRB tendon (lateral epicondylitis muscles) and can lead to microtrauma and degeneration in the tendon (acute Tennis Elbow).

DIY Causes of Tennis Elbow Arm Pain

Again gripping too tightly and trying to get too much done especially when your are not accustomed to doing the task for a long period can lead to overuse of the ECRB tendon and tennis elbow tendinitis pain.

When you use any tool (power tool or hand tool) you need to keep control of where it is pointing and absorb any vibrations – this is done at the wrist.
Using a screwdriver involves supination and pronation movements of the forearm while maintaining an extended wrist which stresses the wrist extensors.
Using a paint brush can involve thousands of repeated flexion / extension movements at the wrist if you are inexperienced and use bad technique and this leads to overuse Tennis Elbow arm pain.

Mouse & Keyboard and Tennis Elbow PC Pain

Prolonged use of a keyboard and / or mouse can lead to Tennis Elbow injuries. This is especially true if the keyboard or mouse is not set up for ‘ergonomic’ use. If the position of the keyboard or mouse means that the wrists are extended or flexed for any period of time then this leads to an increased stress on the forearm tendons at the elbow and produces Elbow Tendinitis pain.
In the same way, reaching out for the mouse or the keyboard can also cause arm pain.
Adjust the height of your keyboard so that you keep your forearms parallel to the floor.

Wii and Tennis Elbow Tendonitis

see my article

Summary

There is no substitute for good technique – get a good coach!
Do not grip too tightly!
Learn how to use the tools properly!

Have you taken my Extensive Professional Tennis Elbow Self-Assessment Tool?
Find out

• what type of Tennis Elbow Lateral Epicondylitis do you have
• if you are doing the correct exercises
• what underlying problems are stopping your elbow from getting better
• if your neck is causing the problem
• and many more things…..

Take the FULL ASSESSMENT at Tenis Elbow Assessment

Back to Tennis Elbow Top 10 Questions

What are your Elbow Pain Symptoms

• Do You Have Severe Elbow Pain?
• Are the Elbow Pains Shooting down your Arm?
• Is your Elbow Painful and Swelling?
• Does your Elbow Lock?

If you answer ‘YES’ to these questions then you should see your Doctor – especially if you have had a fall!

If ‘NO’ then this video checks whether you can fully bend (elbow flexion) and more importantly fully straighten (elbow extension) your elbow.
There are many elbow pain causes and the ability to fully straighten your elbow joint is crucial for people suffering from elbow injuries and pain.
In addition if you suffer from Tennis Elbow injury then it is essential that your elbow straightens fully – otherwise your Tennis Elbow pain will not improve!
Follow the instructions carefully and compare both arms.

Obviously if both arms are the same then this is normal for you!

Have you taken my Extensive Professional Tennis Elbow Self-Assessment Tool?
Find out

• what type of Tennis Elbow Lateral Epicondylitis do you have
• if you are doing the correct exercises
• what underlying problems are stopping your elbow from getting better
• if your neck is causing the problem
• and many more things…..

Take the FULL ASSESSMENT at Tenis Elbow Assessment

Tennis Elbow Injury

It is thought that an Acute Tennis Elbow injury consists of microscopic tears in the attachment of the Extensor Carpi Radialis Brevis muscle to the bone.
This tearing results in the stimulation of the repair process which increases collagen production and new blood vessel growth.
This increase in blood vessels may explain the Tennis Elbow symptoms as well as a local increase in temperature.

Tennis Elbow Symptoms

In the past it was thought that Tennis Elbow Symptoms were a result of a local inflammatory reaction. However it is now more commonly thought that even acute tendinitis is due to a sudden increase in stress which causes further aggravation of an already degenerated area of tendon.
The thinking is that the elbow symptoms are produced by the new blood vessels and their nerves at the repair site rather than from a local inflammatory response.
That is why it is considered more correct to name Tennis Elbow Injury as Lateral Epicondylosis

Lateral Epicondylitis / Lateral Epicondylosis

These are the medical names that you may see for Tennis Elbow.
Epicondylitis – the “itis” indicates that there is acute inflammation taking place (think of Appendicitis).
Epicondylosis – the “osis” refers to a more chronic and degenerative condition.

Both these terms refer to the Lateral Epicondyle which is a raised area of bone on the upper arm bone or Humerus. If you look at the diagram of the back of the right arm opposite you can see that the lower end of the Humerus widens out to form the upper portion of the Elbow joint.
There are two epicondyles one on the inside (medial – labelled A) and one on the outside (lateral – B).

The lateral epicondyle is where the Tennis Elbow muscles (Extensor Carpi Radialis Brevis, Extensor Digitorum and possibly Supinator) attach.
The Extensor Carpi Radialis Brevis muscle is the main culprit in Tennis Elbow.
It is degeneration of the tendon attachment to the Lateral Epicondyle that causes the pain and disability.

Extensor Carpi Radialis Brevis

This muscle has its upper attachment to the Lateral Epicondyle, (B in the diagram), the Radial Ligament and surrounding tissues.

It passes down the forearm deep to the Extensor Carpi Radialis Longus and Extensor Digitorum muscles and lies under the skin in the lower half of the forearm (M in the diagram opposite).

The muscle becomes tendon in the lower forearm and the tendon crosses the wrist and attaches to the base of the 2nd and 3rd Metacarpal bones in the hand (I in the diagram).

The action of the muscle is to help to extend the wrist and deviate it towards the thumb side. (Extension and Radial Deviation)

Summary

You now understand:-

• that Tennis Elbow is micro-tears in Extensor Carpi Radialis Brevis tendon
• that Lateral Epicondylitis and Epicondylosis are the same as Tennis Elbow
• where the Lateral Epicondyle is on the Humerus
• where Extensor Carpi Radialis Brevis attaches and its actions

For more information see Tennis Elbow – Get to Grips

COMING SOON!

ELBOW AND FOREARM ASSESSMENT TOOL

Back to Tennis Elbow Top 10 Questions

Are you sure you have Epicondylitis?

Find out here!

Posterior view of left Humerus

EPICONDYLITIS EPICONDYLOSIS

Epicondylitis – means inflammation of the epicondyle or the structures attached to it. Epicondylosis is probably the more correct term to use as the condition is more often longstanding and this involves degenerative changes in the structures involved.

At the elbow you have two epicondyles one on the inner aspect of the lower humerus – the medial epicondyle (A in fig 1) and one on the outer aspect of the lower humerus the lateral epicondyle (B)

An epicondyle is an bony prominence near the “knuckle end” or rounded surface of the bone that forms the joint. It is there simply to make it easier for muscles or ligaments to attach close to the joint. An epicondyle is a raised bump of bone which has a greater surface area than a flat area of bone so generally you will find several muscles attached to an epicondyle because there is more space.

To control your elbow you actually have 16 muscles which cross the joint. There are four or sometimes five muscles that attach to the lateral epicondyle and four that attach to the medial epicondyle.

Lateral Epicondyle of Left Elbow

ELBOW LATERAL EPICONDYLITIS

In Elbow Lateral Epicondylitis it is the tendon of muscles on the outer elbow that may become inflamed or more likely undergo degenerative changes (generally through overuse or excessive strain) and painful whenever you use them.

The main muscles that attach to the lateral epicondyle are called :-

Extensor Carpi Radialis Brevis & Extensor Digitorum

TENNIS ELBOW LATERAL EPICONDYLITIS

Tenis elbow and lateral epicondylitis are one and the same thing with possible inflammation of the elbow tendons in the acute case, and more commonly, degeneration of the small tendons that connect these muscles to the lateral epicondyle. Tennis Elbow injuries are caused by repeated gripping tasks like DIY jobs and hitting numerous backhand volleys with bad technique. Also recently a very common cause of Tennis Elbow injury is playing the Nintendo Wii for hours. See my post on Wii Elbow.

REFERRED PAIN FROM NECK AND SHOULDER

Irritation of of the nerves in your neck from a disc bulge or some joint inflammation can cause pain to travel down your arm to the elbow and can feel like and present as Tennis Elbow.

Inflammation of soft tissues around the shoulder joint can refer pain down the arm to the elbow which can complicate the diagnosis of Tennis Elbow.

In addition there are a few sites in the arm where one of the the main nerves – the Radial Nerve – can get trapped or irritated and this specifically can replicate the pain and signs of Tennis Elbow!

Are you still sure you have Tennis Elbow?

Take my comprehensive FREE Assessment Tool HERE!

TENNIS ELBOW MUSCLES

These muscles are involved primarily in movements of the wrist and hand, but as they are attached to the humerus they cross both the wrist and elbow joints. In the body the muscles most susceptible to injury generally cross more than one joint. Think of the most common muscles to get injured and you get Hamstrings, Calf, Biceps etc – they all cross more than one joint.

The muscles attached to the lateral epicondyle are

1. Extensor Carpi Radialis Brevis
2. Extensor Digitorum
3. Supinator
4. Extensor Carpi Ulnaris

For More Information – see ESSENTIAL ANATOMY OF FOREARM MUSCLES 

or

TENNIS ELBOW – YOUR TOP 10 QUESTIONS ANSWERED

I want you to understand what Tennis Elbow actually affects, what you need to understand about the condition and then work out for yourself what you can do about it (that’s the DIY bit in DiyInjuryRehab.com).

You’ve probably read it all before about Tennis Elbow being an overuse injury that is caused by repetitive gripping tasks such as using a screwdriver or using power tools, that it affects between 1 and 4% of the population and that 30-40% of tennis players actually do get it!!

Well it’s all true! But I would like to take a slightly different approach. I am going to educate you to fix yourself!

Tennis Elbow can be quite persistent and can be troublesome for anything up to two years. It can become severe and in some cases requires surgery to resolve it! In 75% of cases it affects the elbow on the dominant hand side and this has serious implications for work and sport. It is important to get to grips with Tennis Elbow in the early stages and prevent it from becoming severe and chronic.

These posts on Tennis Elbow will help you understand what the condition involves and what you can do about it now to resolve it.
This post will explain:-

• anatomy of the elbow
• how the elbow moves
• what is tennis elbow?
• what causes tennis elbow?

Elbow Anatomy

There are three bones that make up your elbow joint.

First there’s the upper arm bone called the humerus which runs from your shoulder to your elbow.

Joining with the humerus at the elbow joint are the two forearm bones called the radius and the ulna.
If you stand with your arms by your sides and your palms facing forwards the ulna is the bone on the ‘inside’ nearest to your body.
It forms a ‘hinge’ joint with the humerus.

The radius lies on the outside of your forearm and has a button-like end which takes part in the elbow hinge.
It is also involved with palm up and palm down rotation of the forearm. (Pronation and Supination)

The radius and ulna are joined to each other just below the elbow and also just above the wrist joint.
These joints allow the radius to rotate around the ulna which stays stationary.
To demonstrate this bend your elbow to a right angle with your palm facing up – in this position the radius lies on the outside of the ulna at the elbow and the wrist.
Now if you turn your palm to face downwards the radius crosses over the ulna and now it is on the inside at the wrist (but still the outside at the elbow).
Click on the video for a demonstration.

If you feel the outside of your elbow you will find a distinctly sharp bony prominence which sticks out – this is called the lateral epicondyle. It is the lower part of your humerus bone. If you keep your finger on this bony lump and waggle fingers your will feel the muscles attached to this bump moving under your finger. 

Elbow Movements

As you can see from the video clip above the elbow movements are quite simple.

Flexion is bending of the elbow
Extension is straightening of the elbow
Pronation is when the palm faces down
Supination when the palm of the hand faces up

However none of the muscles that are used to produce these elbow movements are directly involved in Tennis Elbow.

What Is Tennis ELlbow?

It is thought that Acute Tennis Elbow consists of microscopic tears in the attachment of the muscle to the bone.
This tearing results in the stimulation of the repair process which increases collagen production and blood vessel growth.
This increase in blood vessels may explain the pain that is felt as well as a local increase in temperature.

However is is more commonly thought that even acute tendinitis is due to a sudden increase in stress which causes further problems for an already degenerated area of tendon.
The thinking is that the pain is produced by the new blood vessels and nerves at the repair site rather than from a local inflammatory response.

A key feature of chronic inflammation and degenerative changes is collagen production.
If too much collagen is formed, this can lead to a condition known as fibrosis.
As stated above collagen is necessary to replace the tissue lost during long term inflammation or degeneration, however the overproduction of collagen over time can lead to excessive scarring and functional shortening of the muscle interfering with it’s function.
In addition when your elbow is painful for a period of time the your brain adapts and you start to use the muscles in the arm differently and this can lead to problems elsewhere in the arm and neck.
These problems may well have to be corrected before you can use your elbow efficiently again and get rid of your pain – so it is always advisable to be assessed by a good physiotherapist (or other specialist) if you have chronic elbow pain.

Tennis Elbow Causes?

So you may be wondering why most tennis elbow pain seems to associated with gripping – you know that using a screwdriver, stripping wallpaper or practising a tennis backhand aggravates your pain. Well the reason takes a bit of explaining. 
The muscles that attach to the lateral epicondyle all are attached to the bones of the hand and they produce movements at the wrist and hand.

Movements at wrist:

      extension,                         flexion,                       radial deviation,             ulnar deviation.

The muscles associated with Tennis Elbow all produce extension of the wrist, and at least one from the group helps produce radial deviation, and one ulnar deviation.

To grip strongly you need to extend your wrist – this extension gives the muscles on the front of your forearm what is known as a mechanical advantage when producing gripping power.
Try gripping with your wrist fully flexed then the try again with your wrist extended.
It is much easier to generate power with your wrist extended isn’t it!
So although you don’t use the muscles on the back of your forearm to directly produce the grip strength in your hand you use them to help the muscles on the front of your forearm generate the power by positioning the wrist. 

I mentioned earlier that the muscles in the body that cross more than one joint are the ones most susceptible to injury. The simplest explanation for this is opposing movements can be simultaneously taking place at the two joints the muscle crosses.
This places complex movement patterns on the muscle which tries to do two things at the same time which makes it more prone to injury.
In the case of the Tennis Elbow muscles they are positioning the wrist and hand to allow you to get a strong grip- imagine using a screwdriver.
However at the same time you are frequently moving your elbow joint – remember these muscles are attached on the upper side of the elbow.
Trying to maintain the wrist position while moving at the elbow and pronating and supinating the forearm constantly changes the stress on these muscles.
Can you now start to understand why they get overused, are subject to microtrauma and degeneration, and get painful?

In addition to these stresses, raquet sports add further loads to these muscles.
Just imagine the extra load being applied by the impact of the ball on the raquet head in this picture!
The wrist extensors attached to the lateral epicondyle are having to stop the wrist from ‘breaking’ and keeping it firm to control the ball’s flight.
If you remember any of your school physics then you will recall that

EFFORT = LOAD X DISTANCE. 

Now think about the speed of the ball (loosely the Load = mass x acceleration) and look how far the ball is away from the wrist and start to calculate the increase in the ‘breaking’ force at the wrist!!

Be careful not to hit wet tennis balls – they weigh more and increase the load significantly!
Also your racquet needs to be strung appropriately for you. Increased tension in the strings increases the ‘forces’ generated in the racquet. These forces need to be controlled by the wrist and forearm.
It is essential that the grip of your racquet is appropriate to the size of your hand.
If you have any problems I would strongly advise seeking the advice of a professional tennis coach.

That is why you get Tennis Elbow with tennis backhands and also gripping activities, AND why avoiding gripping tightly will help your elbow to get better quicker!!

To summarise, you now should have an understanding of

• the anatomy of the elbow region
• movements at the elbow and forearm joints
• what Tennis Elbow is
• why gripping and raquet sports cause Tennis Elbow