820

REVIEW

Biomechanics of the elbow joint in tennis players and relation

to pathology
Denise Eygendaal, F T G Rahussen, R L Diercks
...................................................................................................................................

Br J Sports Med 2007;41:820–823. doi: 10.1136/bjsm.2007.038307

Elbow injuries constitute a sizeable percentage of tennis BIOMECHANICS OF THE ELBOW IN TENNIS
In the normal elbow joint, stability is maintained
injuries. A basic understanding of biomechanics of tennis and by the combination of joint congruity, capsuloli-
analysis of the forces, loads and motions of the elbow during gamentous integrity and well balanced intact
tennis will improve the understanding of the pathophysiology of muscles. The olecranon and olecranon fossa joint
these injuries. All different strokes in tennis have a different provide primary stability at less than 20˚ or more
than 120˚ of elbow flexion. In between stability is
repetitive biomechanical nature that can result in tennis-related provided by soft tissue constraints, mainly the
injuries. In this article, a biomechanically-based evaluation of UCL.3 4
tennis strokes is presented. This overview includes all tennis- The kinetic chain of the tennis service starts
related pathologies of the elbow joint, whereby the possible with the feet and knees and travels through legs,
trunk/back and shoulder to the elbow joint and
relation of biomechanics to pathology is analysed, followed by finally through the wrist and hand.
treatment recommendations. Biomechanically, the elbow functions primarily
............................................................................. as a link in this kinetic chain, allowing transfer of
kinetic energy from the body to the racquet.
High-speed video analysis studies from Kibler et

T
he increase in the number of participants in al5 have demonstrated that during the service the
sports as baseball, tennis, American football elbow moves from 116˚ to 20˚ of flexion within
and volleyball has resulted in a sharp rise of 0.21 s, with ball impact occurring at approximately
sports injuries and thus to an increased incidence 35˚ of flexion. During groundstrokes, observed
of elbow injuries in recent decades. flexion and extension range was much less
In the Netherlands, a study was conducted averaging 11(46–35)˚ of flexion on the forehand
amongst all patients that received treatment at and 18(48–30)˚ in the backhand. The calculated
the emergency ward of general hospitals between angular velocity during the service motion was
1998–2001; the injury risk was calculated for 982˚/s for elbow extension.5
different group of patients in relation to type of These data reveal the extreme forces that the
racquet sport, age and sex. elbow must repetitiously absorb during tennis
In tennis the injury risk was fairly similar for strokes in flexion and extension direction.
males and females; the older age groups were In most sports with overhead movement,
affected more often and indoor tennis was related including tennis, an increased external rotation
to a higher incidence of injuries in comparison to of the shoulder develops at the cost of internal
outdoor tennis.1 rotation. Elliot has stressed the important role of
The magnitude of forces across the elbow during internal rotation of the upper arm at the shoulder
tennis strokes can produce tremendous valgus during service and forehand strokes.6 This demand
and extension overload in players. The game of on internal rotation of the upper arm during tennis
tennis has been described as a power game can result in an increase of internal rotatory forces
because of the high ball velocities and the across the elbow joint.
explosive physical action of the players.2 In the third plane, valgus and varus, we also can
Biomechanical analysis of these forces, loads and observe abnormal load transfer in tennis. During
motion on the elbow in tennis will lead to an normal elbow motion the axis of the elbow is from
improved understanding of the pathophysiology of varus into valgus as it moves from flexion to
injuries in tennis. extension.3
Common injuries encountered include ulnar This combination of valgus forces and rapid
See end of article for collateral ligament (UCL) tears, flexor-pronator
authors’ affiliations extension during tennis results in tensile forces
........................ muscle tendinosis or tears, ulnar neuritis, posterior along the medial side, compression on the lateral
impingement, ostechondritis dissecans of the portion of the elbow and shear forces in the
Correspondence to: capitellum and tendinopathy of the extensors,
Denise Eygendaal, Amphia posterior compartment. This combination is often
Hospital, Teteringen, The whereby the tendinopathy probably has the high- called ‘‘valgus extension overload’’ syndrome in
Netherlands; denise@ est prevalence in tennis players. overhead athletes and can play a role in some
eygendaal.nl The purpose of this article is to give an over- injuries in the elbow in tennis players.7 8 In
view of elbow injuries and their treatment in
Accepted 26 June 2007
Published Online First adult tennis players in relation to the current Abbreviations: AOL, anterior oblique ligament; OD,
17 July 2007 knowledge regarding biomechanics of the elbow in osteochondritis dissecans; POL, posterior oblique ligament;
........................ tennis. UCL, ulnar collateral ligament

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Biomechanics of the elbow joint in tennis players 821

summary, the tennis stroke puts very high loads on the elbow represents an ‘‘absolute overload’’ of normal anatomy and
joint in extension, internal rotation and valgus, and this occurs physiology due to supra normal forces; possible related factors
in repetitive movements at very high speeds with very high are an excessive wrist snap, ‘‘open stance hitting’’, opening too
forces. soon on serve and short arming of the strokes.5 More research
needs to be performed to clarify the relation of biomechanics in
INSUFFICIENCY OF UCL tennis and flexor-pronator tendinosis.
The UCL complex consists of an anterior oblique ligament
(AOL), posterior oblique ligament (POL) and a transverse band. Ulnar neuritis
The AOL has been shown to be the most important soft-tissue The cause of ulnar neuritis in the cubital tunnel is considered to
constraint to valgus instability of the elbow and is the strongest be the result of mechanical stimuli on the ulnar nerve in the
and stiffest of the collateral ligaments of the elbow with an cubital tunnel.
average failure load of 260 N. The AOL is also the primary Ulnar neuritis around the elbow can be the result of
stabiliser to internal rotatory forces.3 4 compression or traction from valgus stress and can be seen as
The flexor carpi ulnaris muscle, pronator teres and flexor an isolated injury or in combination with UCL insufficiency or
digitorum superficialis form predominantly the musculo- chronic flexor pronator mass tendinosis. Compression can
tendinous unit overlying the AOL; all three muscles have been occur due to a tight cubital tunnel, osteophytes from the ulno-
described to contribute to medial support as secondary humeral joint, muscle hypertrophy or subluxation of the nerve.
stabilisers. In tennis players, the initial presentation of ulnar neuritis can
Acute rupture and chronic overload of the UCL has been be pain along the medial joint line associated with dysesthesias,
described extensively in athletes, especially in baseball pitch- paresthesias or even anaesthesia in the small and ulnar half of
ers.8–12 Findings in acute medial collateral ligament injury are the ring finger. The degree of sensory and motor changes can
moderate to severe elbow pain, acute onset of pain during vary depending on the severity and duration of ulnar nerve
service or a popping sensation followed by medial ecchymosis compression. Surgical intervention is indicated in case of
or even acute ulnar nerve symptoms. Chronic overuse of the progressive muscle weakness, persistent muscle weakness for
elbow, as described before, can also result in progressive more than 4 months, chronic neuropathy or failure of a non-
attenuation of the UCL leading to ligamentous insufficiency surgical regime.19 20 In a cadaver study, the movement of the
even in the absence of a singular catastrophic episode of ulnar nerve at the proximal aspect of the cubital tunnel was
ligament failure. At physical examination the instability can be significantly increased during all throwing phases with
revealed; the degree of laxity is often underestimated. In increased elbow flexion (p,0.05). A mean (SD) maximum
patients with insufficiency of the UCL a typical painful arc can movement of 12.4 (2.4) mm was recorded during the wind-up
be produced using the ‘‘milking manoeuvre’’.12 The diagnosis is phase with maximum elbow flexion. The maximum strain on
confirmed by positive elbow MRI, dynamic stress radiographs, the ulnar nerve during the acceleration phase was found to be
dynamic ultrasonography or positive valgus test at anaesthesia. close to the elastic and circulatory limits of the nerve.21
Treatment can be conservative or surgical.13 Although in this study the ‘‘throwing motion’’ of the elbow
The previous described valgus and internal rotatory forces was studied, the same principles can probably be applied to
result in microtrauma of the UCL and eventually attenuation of motion of the elbow during service. The ulnar nerve is subjected
the ligament. Attenuation of UCL leads to abnormal valgus to longitudinal strain in the cubital tunnel during the service
movement of the elbow joint affecting the mechanics of the motion and this longitudinal strain is increased as the elbow is
highly constrained articulation of the posterior elbow. This in greater flexion.
results in bony impingement at the superomedial corner or the During rehabilitation of ulnar neuritis the amount of flexion
olecranon and the corresponding fossa. Such impingement can during service should be taken into account. As ulnar neuritis
lead to chondral lesion and eventually reactive changes such as can be the result of valgus instability or insufficiency of the UCL
osteophytic spur formation.14 15 the same principles should be applied as described under UCL
In prevention and treatment of UCL insufficiency in tennis insufficiency.
players, therapy should be based on the above-mentioned
biomechanics overload in all three planes of movement, Posterior impingement
extension, rotation and valgus. The ‘‘axis of internal rotation’’ Posterior impingement of the elbow is an uncommon disorder
of the humerus should be addressed, with optimal internal in the general population; it is mainly seen in patients that
rotation of the shoulder, in combination with a proper overuse their elbow during specific sporting activities as such
technique of groundstrokes and service in which the extension overhead throwing or tennis.22 23 The lesion is due to repetitive
should be monitored carefully. The flexor carp ulnaris muscle, combined hyperextension, valgus and suspiration of the elbow
pronator terse and flexor digit rum superficialis have been resulting in a mechanical abutment of bony or soft tissues in
described to contribute to medial stability as secondary the posterior fossa of the elbow. Posterior impingement can
stabilisers. Specific training should be structured to these also be associated with ligamentous instability of the elbow,
muscles to enhance valgus stability of the elbow joint.16 especially UCL insufficiency. In a cadaver study, valgus torques
of 1.25 and 2.0 Nm were applied and kinematic data were
Flexor-pronator tendinosis or rupture obtained with intact and transected UCL at different angles of
Unlike to the common ‘‘tennis elbow’’, or lateral epicondylitis, flexion angle using a 3-dimensional digitiser. For a given load
this tendinosis is more common in high-level tennis players and flexion angle, the contact area decreased and the pressure
than it is in recreational players. The pronator teres and flexor increased with increasing medial ulnar collateral ligament
carpi radialis have been identified as the most common sites of insufficiency. The conclusion was that medial ulnar collateral
pathologic changes.17 18 Athletes complain about tenderness ligament insufficiency alters contact area and pressure between
distal and lateral to the medial epicondyle; resisted wrist the posteromedial trochlea and olecranon and helps explain the
flexion and forearm pronation exacerbate pain. development of posteromedial osteophytes in cases of UCL
Treatment is in general a non-operative program for at least insufficiency.24
6 months; persistent symptoms after 6 months can be an indi- The athlete complains of pain posteriorly, joint effusion,
cation for surgical treatment after exclusion of any other patho- locking, crepitus and a decrease in range of motion, most
logic causes, especially UCL insufficiency. Medial epicondylitis notably an extension deficit. If conservative treatment of

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822 Eygendaal, Rahussen, Diercks

posterior impingement is not successful, arthroscopic debride-

ment of the elbow with removal of osteophytes and synovect- What is already known on this topic
omy can be used in these patients.
In the treatment of posterior impingement, hyperextension N The biomechanics of tennis have been well documented.
of the elbow joint and insufficiency of UCL must be addressed.
N The clinical symptoms of tennis-related injuries and their
treatment have been published over a wide range of
Osteochondritis dissecans
Osteochondritis dissecans (OD) of the elbow is an uncommon
journals.
disorder in the general population. It is usually seen in patients
that overuse their elbow during specific sporting activities in
which the elbow is extended forcefully or axially loaded.25 It has
been described in players with insufficiency of the UCL or What this study adds
players with muscle weakness or hyperlaxity of the elbow
joints. The most important biomechanical aspects of tennis in relation
This injury occurs usually in the lateral compartment as a to the treatment of the tennis-related injuries are described.
result of shear and compression forces to the particular
cartilage or underlying bone of the lateral compartment.
These compressive forces on the radio-humeral joint can injuries. Proper training and preventive exercise, based on
become as high as 500 N, resulting in (Osseo) chondral sound biomechanical research, can result in decrease of loads
fractures and secondary defects in the radio humeral joint.26 across the elbow in tennis players. It is important to recognise
Tennis players mostly complain on a dull and aching pain in that injuries can occur simultaneously and that every entity
and around the elbow shortly after demanding activities. must be treated accordingly.
Findings during physical examination as swelling, tenderness The kinetic chain of the tennis service and strokes should be
over the radiohumeral joint and limitations in motion; taken into account. For example tennis players with more
especially loss of extension is either seen. effective knee flexion-extension during the service action were
Treatment is dependent of the severity, size and location of associated with lower loading at the shoulder and elbow.30 The
the lesion and age of onset and can be conservative or surgical. exact impact of this finding is as yet unknown and needs to be
Underlying valgus instability should be addressed accordingly further investigated.5
and hyperextension should be avoided. Internal rotation of the upper arm at the shoulder during the
service and forehand is of utmost importance; decrease of
Lateral epicondylitis internal rotation in the shoulder can increase rotatory stress on
Lateral epicondylitis is 7–20 times more common than its the elbow. Internal rotation of the upper arm and pronation of
medial counterpart and produces pain along the lateral elbow the forearm during the early phase of the follow-through of the
and forearm. Treatment is generally conservative. In cases service probably reduce these forces on the elbow.2 Grip size
lasting more than a year, surgery can be considered. does not seem to play a role in elbow injuries; playing with a
Lateral humeral epicondylitis is a condition that primarily ‘‘Western grip’’ can possibly increase valgus stress on the
occurs in the recreational tennis player. One of the reasons is an elbow, especially during acceleration.2
increase of wrist extension in more experienced players just Strengthening the forearm flexor muscles and reducing
prior to ball impact. Novice players strike the ball with their elbow extension after impact might help reduce injury risk.
wrist in more flexed position at impact.27 In general, most symptomatic conditions of the elbow in
Observations of the patterns of activation and joint kine- tennis players can be treated conservatively initially. In cases
matics of novice tennis and advanced payers, using kinematic where conservative treatment is not successful, surgical
data in conjunction with a computer model, have revealed intervention is indicated. In conservative and surgical treat-
substantial eccentric contractions of the extensor carpi, which ment protocol analysis of the biomechanics of each tennis
are likely the cause of repetitive microtrauma leading to tennis player must be performed and abnormalities addressed.
elbow injuries. Adopting the technique seen in advanced
players probably helps limit the eccentric contractions and .......................
reduces the likelihood of injury.28 Tennis grip size was believed Authors’ affiliations
to play a crucial role in the past. However, based on fine-wire Denise Eygendaal, Amphia Hospital, Teteringen, The Netherlands
electromyography studies in which muscle activity in extensor F Th G Rahussen, Sint Maartenskliniek, Nijmegen, The Netherlands
carpi radialis longus and brevis, extensor digitorum communis, R L Diercks, UMCG, Gronigen, The Netherlands
flexor carpi radialis and pronator teres were measured, tennis Competing interests: None declared.
racquet grip size (1/4) above or below Nirschl’s recommended
measurement does not significantly affect forearm muscle
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