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Key aspects of a rehabilitation programme 1. Correct any fault in synergistic recruitment of forearm extensors and flexors during grip. There is often an imbalance producing excessive strain through the extensors based on excessive extensor contraction when finger flexors are activated to grip the handle

2. Encourage a smooth independent movement of the wrist, elbow and shoul- der during the groundstroke while maintaining grip at ball strike

3. Lessen and correct any imbalance of shoulder kinematics and improve on periscapular muscle stability and co-ordinated recruitment to optimise the scapulo-humeral rhythm. This type of rehabilitation is ideally approached using Pilates-evolved equipment and techniques to assist muscle activity and to control movement patterns specific to tennis

4. Active exercises without resistance - extension, flexion, circumduction of wrist and forearm supination and pronation

5. Isometric contractions included in each wrist and forearm position 6. Strength exercises with 1-2lb (0.45-0.91kg)weights or resistance tubing progressing as tolerated (see fig.7)

7. Maintain rotator cuff and trunk balance and stability 8. Sport specific resistance work using resistance tubing 9. Return to pre-injury level of play. Introduce backhand drive and backhand volleys later in training.

References 1. Bernhang AM: The many causes of tennis elbow. New York State Journal of Medicine 1979:1363-1366 2. Blackwell JR, Cahalan T. Wrist positions in skilled and unskilled tennis players at ball- racket impact: Implications for the onset of lat- eral epicondylitis (tennis elbow). First World Congress of Biomechanics 1990 3. Giangarra CE, Conroy B, Jobe FW et al: Electromyographic and cinematographic analy- sis of elbow function in tennis players using single- and double-handed backhand strokes. Am J Sports Med 1993;21:394-399 4. Kuessner U: Vibration dampeners. Do they work? Tennis Australia 1991;16:57 5. Grabiner MD, Groppel JL, Campbell KR. Resultant tennis ball velocity as a function of

Author’s recommended books

off-center impact and grip firmness. Med Sci Sports Exer 1983;15:542-544 6. Hatze H. Forces and Duration of Impact, and Grip Tightness During the Tennis Stroke. Med Sci Sports Exer 1976;8:88-95 7. Adelsberg S. The tennis stroke: An EMG of selected muscles with rackets of increasing grip size. Am J Sports Med 1986;14(2):139-142 8. Morris M, Jobe FW, Perry J et al. Electromyographic analysis of elbow function in tennis players. Am J Sports Med 1989;17:247 9. Cabrera JM, McCue FC. Nonosseus athletic injuries of the elbow, forearm and hand. Clin Sports Med 1986;(4):681-700 10. Henning EM, Rosenbaum D, Milani TL. Transfer of tennis racket vibrations onto the human forearm. Med Sci Exer 1992;24:1134- 1140

11. Nirschl RP. Muscle and tendon trauma: Tennis elbow. In Morrey BF (ed): The Elbow and its Disorders, ed 2. WB Saunders 1993 12. Moss SH, Switzer HE. Radial tunnel syn- drome: A spectrum of clinical presentations. J Hand Surg 1983;8:414 13. Lee DG. Tennis elbow: A manual therapist’s perspective. J Orthop Sports Phys Ther 1986;8:134-141 14. Gieck JH, Saliba E. Application of modali- ties in overuse syndromes. Clin Sports Med 1987;6:427-466 15. Halle JS, Franklin RJ, Karalfa BL. Comparison of four treatment approaches for lateral epicondylitis of the elbow. J Orthop Sports Phys Ther 1986;8:62-67 16. Stratford P, Levy DR, Gauldie S, et al. The evaluation of phonophoresis and friction mas- sage as treatments for extensor carpi radialis tendonitis: A randomized controlled trial. Physiother Can 1989;41:93-99 17. Gogia PP, Brown M, Al-Obaidi S. Hydrocortisone and exercise effects on articular cartilage in rats. Arch Phys Med Rehab 1993;74:463-467 18. Kibler WB, Chandler TJ. Sport specific con- ditioning. Am J Sports Med 1994;24(3):424- 432

19. Nirschl RP. Tennis elbow. Orthop Clin North Am 1973;4:787 20. Groppel JL, Nirschl RP. A mechanical and electromyographical analysis of the effects of various joint counterforce braces on the tennis player. Am J Sports Med 1986;14:195 21. Burton AK. Grip strength and forearm straps in tennis elbow. Br J Sports Med 1985;19:37- 38

Dr Simon Petrides is a sports and muscu- loskeletal physician who originally trained in medicine, osteopathy and sports medi- cine. He is director of the Blackberry Sports and Orthopaedic Clinic in Milton Keynes.

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