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Swinging With Moxy
Dr. Kenneth C. Thomas BS, MS, DC, CCSP
Tennis Elbow is the common name describing the painful condition Lateral Epicondylitis (LE), speculatively caused by overuse of the forearm resulting in elbow pain.  To no surprise, playing tennis and other racquet sports can be a culprit for its development. However, a variety of other activities or sports can also be the cause of this painful condition. Painters, plumbers, carpenters or others frequently and repetitively employing the use of forearm extensor muscles with gripping objects are prone to developing tennis elbow.
Keep in mind the diagnostic term phrase Lateral Epicondylitis is a slight misnomer, as the condition is not entirely inflammatory in nature, but rather degenerative by way of micro-tearing between the common extensor tendon and periosteum of the lateral epicondyle of the humerus. [1;2;8] In some literature, this same condition is identified as Lateral Epicondylalgia. 
Here we define the parameters surrounding the condition, as well as provide general procedures for properly detecting, diagnosing, and treating tennis elbow with conservative and natural therapies. Additionally, our discussion leads to a discussion of possible means of preventing the condition from developing.
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Chances are most people complainof pain on the outside (lateral) portion of their forearm near or at the elbow. While there are many causes of forearm or elbow pain, LE will stand out and is relatively easy to distinguish from other conditions. With observation and a concentrated upper extremity examination of the elbow, you may identify the exact location of the pain and during which motions the pain is reproduced. With someone suffering from LE, the common extensor tendon of the forearm will present as either painful or dysfunctional, or both. [4-6]
The four muscles sharing the common extensor tendon origin site at the lateral epicondyle include the Extensor Carpi Radialis Brevis, Extensor Carpi Radialis Longus, Extensor Digitorum, and Extensor Carpi Ulnaris; more deep muscle, the Supinator muscle also originates at the lateral epicondyle.
The specific tendon involved with LE is that of the Extensor Carpi Radialis Brevis (ECRB), which acts to stabilize the wrist when the elbow is straight. With its small origin, it transmits large forces through its tendon during repetitive grasping of objects. The repeated biomechanical motion of a tennis groundstroke is an example of the type of motion that could lead to the gradual wearing of the muscle at its origin. In some instances the sheer stress of all movements of the forearm gradually causes micro-tearing of the tendon, resulting in the buildup of scar tissue and thickening of the tendon. [7;8]
The Extensor Digiti Minimi, responsible for extension of the little finger (5th phalanx) and some extension of the wrist, has a small origin site at the anterior portion of the lateral epicondyle of the humerus. Its action allows for a flicking motion of the wrist associated with the swinging of a racquet.
The etiology of the condition described in literature suggests it arises from repetitive overuse, strenuous activity requiring speed and/or repetitive eccentric contraction of forearm muscles, and the controlled lengthening of the wrist extensor muscle group. Non-inflammatory, chronic degenerative changes of the common extensor tendon are identified in surgical pathology specimens.  Without delving too deeply into the energetics of muscular activity, it is poignant to mention that the energy demands of contracting even small skeletal muscles containing thousands of muscle fibers are enormous. In a continually contracting muscle, the fibers require specific nutrients and oxygen to sustain its continued use before it ultimately deteriorates.
Perhaps because of a lack of a fueling nutrient supply, available literature discussing this injury identifies overuse as a common indicator.  The form of overuse most aptly implied is through repetitive hand movements, especially the biomechanics necessitating excessive deviation of the wrist from its neutral position into extension, or even the high levels of physical strain to the wrist we described. [10-12]
Mental chronometry, the response time in perceptual-motor tasks, is implicated as a possible factor for LE.  This points to the function of the nervous system and its transmission of information from the brain to the physical motor activity of a given body part. The processing of input and the resulting execution of an action is measured for efficiency of processing information to perform the biomechanical operations needed for the task at hand.
Although diagnostic imaging is not considered an essential diagnostic procedure for diagnosing LE, it may be considered if a more serious pathology is suspected. With LE, an MRI will reveal common extensor tendon thickening at the lateral epicondyle. [11;14]
Several other clinical tests reported to be moderately valid for diagnosing LE include:
Note that palpation a fingerbreadth distal to the lateral epicondyle revealing tenderness, although accepted as a reliable and valid procedure, is based on traditional indication rather than scientific investigation.
In light of one surgeons review of non-therapeutic modalities being unproven at best,  the efficacy of conservative treatment procedures have not distinctly been demonstrated, even through rigorous clinical trials. However, in several randomized controlled trials (RCTs) improvements in the LE conditions were noted. Of these conducted, youll be delighted to learn that mobilization/chiropractic manipulative adjustments to the wrist prove statistically superior to other treatment protocols including (i.) the combined use of ultrasound, friction message, exercise and stretching, and (ii.) corticosteroid injections. [1;3] Perhaps due to wrist segmental dysfunction where the extensor muscle group inserts at the metacarpals and proximal phalanges the biomechanics of normal muscle function are altered. [17-20]
Although controversial in the most recent reviews of orthotic wraps and bracing, a top rated treatment of LE was the implementation of the orthotic device known as the Dynamic Extensor Brace,  which holds the wrist in its extended position and reduces the electromyographic activity of the wrist extensor muscle group during gripping activity.
Exercise and stretching as an intervention shows that eccentric contraction exercises are more effective than contract-relax stretching exercises for complete recovery of the condition. [18-20] Yet stretching of the extensor muscle group also proves to assist with ameliorating the condition to some degree. 
Light elastic taping techniques are advocated for chronic musculoskeletal conditions such as lateral epicondylalgia. Although little evidence exists supporting the effects of taping techniques on musculoskeletal pain, the few studies conducted demonstrate its efficacy.  Perhaps because the light elastic taping is effective in providing support to muscle function, as well as improving circulation and oxygen supply to the surrounding area where applied, it allows muscles and tendons to repair more quickly.  A preliminary study demonstrated an initial ameliorative effect of a taping technique for LE and suggests that it should be convoluted as an adjunct in the management of this condition. 
Conservative therapies that were rated low on efficacy included Ultrasound, and Low Level Laser. [22-25]
Because laser therapy as well as light elastic taping techniques are relatively new therapeutic technologies, not too many studies examining their implementation have been conducted. Thus, the lack of evidence-based research is likely the basis for their lack of being considered the most effective treatments. 
As it relates to playing sports - experience, ability, technique and the use of appropriately sized equipment may all be factors to consider when preventing LE. 
Other preventative measures to consider include:
As one might suspect, insufficient dietary nutrient intake can contribute to the deterioration of any of the bodys parts. Thus, diet is a factor when considering the presentation of any ailment involving muscles, ligaments, and tendons. Nutritional supplementation shows enormous benefits with generally supporting the body in its natural functions. As it pertains to supporting tendons, supportive nutrient supply may benefit from some of the following:
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