Brief Communication
Tennis elbow: Further considerations ROBERT
P.
NIRSCHL,
MD, Arlington,
Virginia The
following
is in response to the
tion and thrust (shoulder action) associated with precise impact timing and racquet control (forearm) are all crucial to maximum result. The forearm position varies markedly in relation to grip and type of shot executed. My observation has been that the inexperiappreciate Dr. Minkoff s thoughtful eval- enced player’s forearm is more consistently uation of the paper. He correctly points out in full pronation at backhand impact than the areas of strength (eg, tennis elbow at that of the more experienced player. Cavarious levels of skill; style and mechanics; daver examination reveals the extensor apopathological findings; overall treatment de- neurosis to be under increased tension (by sign) and areas of weakness (ie, apparent palpation) with passive pronation. In addilack of solid substantiation). tion, full forearm pronation is often associThe paper was begun in January, 1972 ated with humeral internal rotation. As a and represents a clinical approach which result of this arm position, the racquet head reflects my experience with approximately subjects the forearm extensors to a full, 500 cases of tennis elbow. The treatment vertical anti-gravity acceleration force as has had failures 5 cent well as impact and torque forces. These design (approx. per surgical rate) but, in general, has been quite stresses result from the pronated arm position and are characteristic of the inexperisuccessful. In a future paper, I will review concepts of treatment, and present hard data enced player’s backhand ground stroke. I would agree with Dr. Minkoff’s com(lacking in the present paper) which will undoubtedly change or shift emphasis in ment that forearm girth measurement and some of our current approaches. grip strength determination (dynamometer) Dr. Minkoff, in his discussion, asks for are of no help without additional paramemore explicit definitions. Perhaps the folters. Unfortunately, we have no effective means to accurately isolate and record lowing will suffice. World-class economy of stroke production forearm extensor muscle strength. Girth and refers to the lack of excess or extraneous strength measurements can only be used to movement (eg, short or non existent backsuggest what that actual situation is likely to swings, maximum tensing of upper ex- be. Evaluations of resistance and muscle tremity muscles only at moment of impact, tone by the examiner have similar disadvanetc.). The observations were made after tages. slow-motion movie analysis and personal I believe the medial slope of the lateral interviews with world-class tennis players. condyle is normal to the human elbow. The Dr. Minkoff agrees that weight transfer is position of the arm on X-ray and the angle the power source but I must point out that of view are indeed critical. The most comwhat I have written and what he agrees with mon error in the x-ray examination results from the internal rotation position of the are in error. Forward weight thrust (body humerus during the x-ray. Dr. Minkoff is momentum via leg action) plus circumduc-
of Dr. Jeffrey Minkoff , New York City, regarding Dr. Nirschl’s pa, The Etiology and Treatment of per Tennis Elbow (The Journal of Sports , 1974 , Number 6 , Volume 2 Medicine . ) comments
48
correct in stating that a disadvantaged leverage force system is better inferred rather than concluded. Dr. Tichauer’s work relative to heat generation and thermography is noted only to show that pronation and supination increases heat in the region of the lateral epicondyle with gradual extension distally along the area of the extensor muscle mass. These same characteristics have not been
The hormonal aspects of women’s athletic were mentioned as a speculative issue. A major prospective study must be undertaken to assess the wide potential ramifications of this problem. We have found that an awareness of this important factor can be clinically helpful on occasion. I wish to commend Dr. Minkoff on his discussion. Much needs to be done and exchanges of ideas such as this, certainly speed the
demonstrated
process.
medially.
performance
49
Tennis elbow: Further considerations ROBERT
P.
NIRSCHL,
MD, Arlington,
Virginia The
following
is in response to the
tion and thrust (shoulder action) associated with precise impact timing and racquet control (forearm) are all crucial to maximum result. The forearm position varies markedly in relation to grip and type of shot executed. My observation has been that the inexperiappreciate Dr. Minkoff s thoughtful eval- enced player’s forearm is more consistently uation of the paper. He correctly points out in full pronation at backhand impact than the areas of strength (eg, tennis elbow at that of the more experienced player. Cavarious levels of skill; style and mechanics; daver examination reveals the extensor apopathological findings; overall treatment de- neurosis to be under increased tension (by sign) and areas of weakness (ie, apparent palpation) with passive pronation. In addilack of solid substantiation). tion, full forearm pronation is often associThe paper was begun in January, 1972 ated with humeral internal rotation. As a and represents a clinical approach which result of this arm position, the racquet head reflects my experience with approximately subjects the forearm extensors to a full, 500 cases of tennis elbow. The treatment vertical anti-gravity acceleration force as has had failures 5 cent well as impact and torque forces. These design (approx. per surgical rate) but, in general, has been quite stresses result from the pronated arm position and are characteristic of the inexperisuccessful. In a future paper, I will review concepts of treatment, and present hard data enced player’s backhand ground stroke. I would agree with Dr. Minkoff’s com(lacking in the present paper) which will undoubtedly change or shift emphasis in ment that forearm girth measurement and some of our current approaches. grip strength determination (dynamometer) Dr. Minkoff, in his discussion, asks for are of no help without additional paramemore explicit definitions. Perhaps the folters. Unfortunately, we have no effective means to accurately isolate and record lowing will suffice. World-class economy of stroke production forearm extensor muscle strength. Girth and refers to the lack of excess or extraneous strength measurements can only be used to movement (eg, short or non existent backsuggest what that actual situation is likely to swings, maximum tensing of upper ex- be. Evaluations of resistance and muscle tremity muscles only at moment of impact, tone by the examiner have similar disadvanetc.). The observations were made after tages. slow-motion movie analysis and personal I believe the medial slope of the lateral interviews with world-class tennis players. condyle is normal to the human elbow. The Dr. Minkoff agrees that weight transfer is position of the arm on X-ray and the angle the power source but I must point out that of view are indeed critical. The most comwhat I have written and what he agrees with mon error in the x-ray examination results from the internal rotation position of the are in error. Forward weight thrust (body humerus during the x-ray. Dr. Minkoff is momentum via leg action) plus circumduc-
of Dr. Jeffrey Minkoff , New York City, regarding Dr. Nirschl’s pa, The Etiology and Treatment of per Tennis Elbow (The Journal of Sports , 1974 , Number 6 , Volume 2 Medicine . ) comments
48
correct in stating that a disadvantaged leverage force system is better inferred rather than concluded. Dr. Tichauer’s work relative to heat generation and thermography is noted only to show that pronation and supination increases heat in the region of the lateral epicondyle with gradual extension distally along the area of the extensor muscle mass. These same characteristics have not been
The hormonal aspects of women’s athletic were mentioned as a speculative issue. A major prospective study must be undertaken to assess the wide potential ramifications of this problem. We have found that an awareness of this important factor can be clinically helpful on occasion. I wish to commend Dr. Minkoff on his discussion. Much needs to be done and exchanges of ideas such as this, certainly speed the
demonstrated
process.
medially.
performance
49
