Pain syndromes around the elbow in elite tennis players are common. Flexor or extensor tendinopathy (medial and lateral epicondylitis) are well known to us all. However, recently it has become apparent that there are a significant numbers of players presenting with a different pattern of pain from a different source. These players initially complain of pain specifically with serving and later with ground strokes and volleying. The pain is deep and aching, punctuated by sharper more severe pain on ball impact. The pain location is typically hard to localise but is felt both proximal and distal to the elbow. After a match the arm is heavy and the player may complain of difficulty lifting the arm against gravity or with a load applied. Examination usually reveals no tenderness over the medial and lateral epicondyles but significant discomfort palpating the distal humerus medially or laterally or both, through the gap between triceps and biceps. Plain X-rays are usually normal. Bone scans will show linear uptake along the medial or lateral border of the distal humerus but MRI scanning reveals bone marrow oedema of varying length and intensity with no cortical breach demonstrated. Therefore the diagnosis is more of a stress reaction rather than true stress fracture. Interestingly six out of nine players with this condition in our initial series from the Australian Open 2002, also had concurrent ipsilateral shoulder problems which may explain why the distal humerus maybe being overloaded to compensate for insufficient power generation more proximally. At this stage rest is the only treatment option whilst trying to identify and address risk factors which may include service technique. The take home message is to be aware of this condition when consulted by a player with vague, non-specific pain around the elbow of the dominant arm. We anticipate publishing the formal data later this year.
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