By A. Martin Clark M.D.
Illustration by Tony Cristovich
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“Squash elbow” sufferers experience pain at the outside of the elbow. The point of the pain is the Lateral Epicondyle area where the extensor muscles of the forearm that extend the wrist, attach to the Humerus.
US Champion Marty Clark completed his M.D. from Columbia University and is now working on his residency in orthopedic surgery. As with all medical advice, consult your physician before adopting any fitness regime and before taking any prescription or non-prescription drugs. |
In 1883 while one of our sport’s ancestors was busy batting the squash ball against a debtors’ prison wall in England, his more sophisticated cousin was prancing around a well-trimmed lawn in all white playing tennis. At the end of the day both men noticed that once again they were tender at the bony part of the elbow. No one seems to remember the squash-playing chap proclaiming that he was again having a flare-up of his “squash elbow.” The other man described his condition as “lawn tennis elbow” and the name stuck.
Tennis players aren’t the only ones who feel this pain, though. Many squash players, baseball pitchers, swimmers, fencers, and even carpenters and plumbers are plagued with “tennis” elbow. Why? Certain entheses (junctions of bone with tendon or ligament) are susceptible to stress from repeated use. One such area is the point where the muscles that extend down to the wrist originate: just below the outside bend of the elbow (see illustration below). On a microscopic level, the tendons in this region become hypercellular, degenerative, and microfragmented with generalized angiofibrotic infiltration and disorganization. Translation: the tendons become thickened, gray, and swollen—and it hurts.
The typical patient is a 35-50 year old athlete (male or female) who plays his or her sport a few times a week and finally relents to seeing the doctor after a gradual—and painful—onset of symptoms over the course of months or years. Once the squash enthusiast finally decides to seek treatment for the nagging “squash elbow,” he or she is halfway there. The diagnosis is fairly straightforward. (Do, however, make sure that your doctor rules out osteoarthritis of the elbow joint and entrapment of the posterior interosseous nerve. And ask if the nerve is compressed in your congenitally narrow Arcade of Frohse—for extra credit!)
For tennis elbow, most physicians will recommend a course of rehabilitation that should include the following phases:
Phase 1, the goal is to decrease pain and inflammation of the affected area, and the key to this phase is rest. Icing the affected area, massage, and anti-inflammatory medication are some of the primary treatments. Some patients may benefit from wrist extension splints for a short period of time as a reminder not to use the affected hand as much. Moderate conditioning may be a part of this phase as long as the exercises do not cause pain.
Phase 2 involves active stretching, strengthening, and re-introduction of functional activities. The stretching exercises have three components: wrist extension, wrist flexion, and rotation. First, hold the hand of the affected arm in a stretched position for 10 seconds and do five sets in both flexion and extension. These stretching sessions should be repeated two to three times daily. Second, tie a weight on a string to a two-foot long bar. Start first with palms facing downward gripping the bar with alternating wrist extension of both hands (like accelerating a motorcycle), and wind the weight up to the bar. Do two to three sets before turning the bar over and repeating the exercise with the palms facing upward. This second exercise, also repeated two to three times, strengthens the wrist flexors. Ask your doctor or therapist for additional exercises for the rotator cuff muscles of the shoulder if total arm strength and conditioning may be part of the problem. (Note: During phase 1 and 2 some patients have benefited from electric stimulation or a mixed injection of steroid and local anaesthetic. Due to possible side effects ask, your physician if either of these treatments is appropriate for you.
Phase 3 finally marks the return to the sport or work activity that led to the pain. Assess your equipment and technique to check for any problem spots. Get a racquet that is light enough for you; a quality high-tech light racquet will help you make more consistent contact with the ball in the sweet spot and reduce the chance of using the wrist to compensate for poor racquet preparation. Slightly thicken your grip so that there is greater leverage for torsion control of the racquet. Loosen the strings on your racquet: This will lessen the vibrations upon hitting the ball, and the give of the strings will generate pace. Take a technique lesson. Too many of us are convinced that our sport is a “wristy” sport by design, but good technique, as in all sports, is based on footwork. Improved technique will decrease arm pain and increase consistency in your game. Finally, add a counter-force brace to your court kit; the brace is a non-elastic support that wraps around the upper forearm, thus constraining muscular expansion and decreasing the force on the sensitive spot.
With these rehabilitation exercises and by carefully following the instructions of your doctor, you should be able to return to playing squash in good time and avoid surgery |
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