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'Lo Bent Sinew:'
The Metamorphosis of Tennis Elbow
by Dr. Charles E. Berkoff

Introduction

It's hard to read a tennis magazine, or visit a tennis website, and not find yet another article on 'Tennis Elbow' (TE). And they all seem to trot out the same old, boring, and yes, misleading information and advice.

It's harder still to go within a mile of one's tennis club and not be molested by grimacing 'TE sufferers,' forlorn-looking hackers who insist on sharing with you their every painful arm movement.

"And it really hurts when I do 'this,'" they proclaim.

"So, don't do 'this'" you advise. Alas, next encounter, same routine.

But enough. It's time we examined all the facts, and put the typical tale of misery and woe into a new and frankly exciting perspective. In sum, TE is not punishment; not a handicap; not the scourge of tenniskind. For players, it's an asset. A distinct advantage. An 'ad in,' in fact. And with new understanding, we now know why.

Let's first look at the current status of TE, starting with a brief review of the medical features. 'Tennis Elbow' is a phrase that's been used to describe almost any pain in the forearm or elbow; usually on the outside, sometimes on the inside. Outside pain, Lateral Epicondolytis, is inflammation of the tendons (tendonitis) that attach the extensor muscles of the forearm to the elbow. Medial Epicondolytis occurs on the inner portion of the elbow. And the origin? Well, for tennis players it's typically poor stroke technique — especially on the backhand side. The 'problem' is also common to golfers, carpenters, and even politicians who grab too many hands (and things). Frankly, I'm concerned about non-tennis players becoming involved. Tennis Elbow is a tennis asset, and other 'beneficiaries' should at least pay the USTA royalties.

In any event, while TE is a source of pain, it isn't a problem. In point of fact, we're blessed with an incredibly sophisticated and exquisitely sensitive warning system, physical pain, that dissuades us from doing dumb things. And that, of course, is the purpose of this kind of pain. Instead of playing an imperfect shot and having a pro say something like "keep your eye on the ball," or "turn your shoulder," we have our own, built-in personal coach. When our shot is less than perfect, we receive a gentle reminder: a friendly stab of white, hot pain. Do it right and there's no pain. Thus a player who never experiences TE either has excellent stroke mechanics or, as we now know, suffers from a biochemical deficiency. Those of us who have, or have had, TE are privileged and must commiserate with our armbraceless colleagues, the pain free, the TE-challenged, the truly handicapped.

History

The origin of tennis dates back to the Stone Age, when early man first used a club to hit rocks over a mound of dirt. Ironically, we (well, some of us) now belong to clubs, play on the dirt, and serve (or at least receive) rock(et)s. The earliest recorded history of TE is attributed to the Y0K cave dwellers of pre-biblical Carthilage who depicted TE as a bent arm clutching a stick, with two-headed serpents writhing within forearm and elbow. Over the centuries, the focus of TE gradually shifted from Ancient Greece, to Rome, to the Royal Courts of 10th century France and, finally, to the civilizing influence of 13th and 14th century England. But 'the problem' was yet to be described as 'Tennis Elbow.' Symbolic serpents were still the currency of the day.

Etymology

As is often the case with language, origins may be obscure; the phrase, 'Tennis Elbow,' is no exception. Etymologists tell us that there are two prevailing hypotheses; both have their beginnings in 17th century England.

The first supportable sequence of events is believed to stem from a well-documented outbreak of TE in London in July, 1665. With ever-increasing anxiety, sufferers frantically searched for anyone willing to listen to their woes. In desperation, they organized themselves into an Association, whose members would meet in a modest building at 10 Nisel Street, Bow, London. Over time, their address was shortened to 10 Nisel, Bow … i.e. TenNiselBow. Meetings of the later-named, Tennis Elbow Association, TEA, were held promptly at 4:00 p.m. every day, an hour that rapidly became known as 'TEA time.' [The author, who was born in Bow, London - a lob away from Nisel Street - well remembers the TEA headquarters which were actually located above a small brothel. As a young boy, it always surprised him how many tennis players visited the TEA center to, as they put it, take care of their serpents!]

A second and arguably more appealing explanation is said to originate with William Shakespeare. Will was, of course, passionate about his tennis - to a point of obsession. He regularly enjoyed mixed doubles with wife Anne, and his many references to tennis throughout his writings are well chronicled: "… strong sides can volley …" (Anthony and Cleopatra); "… the forehand of our host …" (Troilus and Cressida); "… the faith they have in tennis…" (King Henry VIII); "… in that vast tennis court …" (Pericles, Prince of Tyre); "… an ace for him …" (A Midsummer Night's Dream); "… tennis balls, my liege …" (King Henry V). Etc., etc. In all, he cites: tennis (5 times), deuce (2), ace (5), ad (4), forehand (3), lob (2), overhead (1), volley (4), net (10), serve (152), game (23), set (441), and match (80). 'Love' is mentioned no less than 1663 times.

Less well known is a letter he wrote on August 8, 1606 to his estranged wife, Anne Hathaway, referring to his tennis-inflicted misery as: 'Lo Bent Sinew!' 'Lo' was very frequently used in Shakespeare's time to call attention to an object (cf. 'lo and behold'). According to documents preserved by the British Museum, Anne was unsympathetic to his bent sinew, and concerned herself only with his tardy 'alimonye payements.'

Shakespeare's colorful phraseology was then taken to its next and final phase by tennis aficionado and TE-sufferer, William Penn, in June, 1665. Renowned for his Pennmanship, the future Governor of the State of Pennsylvania became preoccupied with Shakespeare's writings and toyed endlessly with his 'Lo Bent Sinew.' 'Tennis Elbow' emerged as a simple but particularly apt anagram of Shakespeare's more picturesque language. Thus, together with his distinctive balls, Penn's 'Tennis Elbow' passed quietly into modern English usage.

History records that, in addition to Shakespeare and Penn, other notable TE sufferers were: Venus di Milo, Ghengis Khan, Geronimo, Josef Stalin, and Mother Theresa. Venus (The First!), whose TE was particularly severe, yielded to the preferred treatment of the day, and had both arms 'ripp'd off' to relieve the insufferable pain. She was so sculpted in the summer of 150 BC.

New Developments

Recent advances in our understanding of the chemical and molecular biological basis of TE have been little short of extraordinary. The two-headed serpents depicted in BC times notwithstanding, an infectious entity was long held to be the origin of TE in Europe. The poorly understood organism, Mycoplasma tennisium, was suspected to be the causative agent and, based on the statistically significant occurrence of TE among mixed doubles partners, it was further believed that TE was sexually transmitted. Dr. Ravel of the Imperial College, University of London, has now discredited these views by isolating Mycoplasma tennisium, and using nuclear magnetic resonance spectroscopy, has shown it to be nothing more than tightly coiled filaments of tennis ball fuzz.

As part of the remarkably ambitious international human genome project, where one of the primary goals is to identify all of the 30 - 40,000 or more genes in human DNA, particular focus has been on the search for a genetic origin of Tennis Elbow. After many years of intensive study, the collaborative efforts of Professor Pryer and his research team at The Johns Hopkins University; Dr. Dentil, Nobel Laureate, and his co-workers at Harvard University; and Mr. Swellaro, East Hoboken Community College, finally led to the identification of the gene responsible for TE. The TE gene, ATP40-30 (ATP: Adenosine Triphosphate — not Association of Tennis Professionals), was mapped to chromosome 6261; it codes for the new and now fully characterized protein, endorservin. The e-factor.

Dr. Oscalet of the Roland Garros Centre de Recherche in Paris, has revealed that endorservin (e) is secreted by the microscopically small, ball-shaped TE gland located in the coronoid fossa region of the elbow. The gland lies dormant until its secretory activity is triggered by severe agitation of the elbow; the impact of hitting tennis balls is believed to be sufficient to initiate the process.

On Wednesday, Dr. Gennell, President & CEO of the Tenni-Tech Laboratories in San Diego, announced the development of a simple, saliva-based test designed to determine endorservin levels to 0.00009% accuracy.

And on Thursday, a completely unexpected finding: Using the Tenni-Tech technology, Drs. Ernshaw and Shea, Ringling School of Medical Design, Sarasota, Florida, determined that all of the top 100 professional tennis players (with ratings of 7.0) had circulating endorservin levels of 6.98 - 7.00 picograms/milliliter. 2.5-rated hackers recorded e-levels of 2.50 - 2.99 pg/ml; 3.0-rated players typically registered 3.00 - 3.49 pg/ml; 3.5 players fell in the range 3.50 - 3.99 pg/ml; etc., etc. Incredibly, the good doctors had discovered an accurate, rapid, and totally objective (i.e., a no-cheat) National Tennis Rating Program system! It was beautiful. Of course, the lower the e-level the more vulnerable we are to TE discomfort.

These astonishing developments now lead the tennis world to the obvious question: Since skilled tennis players have high e-levels (and negligible TE problems), is the converse true? i.e. Can we improve on our tennis skills (and reduce TE liabilities) simply by raising our e-levels? To become a better tennis player without actually working for it continues to be the dream of most club players. A larger racquet, a lighter racquet, colored strings, a new sports drink ….. we try them all. It's not surprising, therefore, that much attention is now focused on increasing e-levels ….. not by mastering stroke technique, but by the exciting, chemically-mediated possibility of ….. taking something … a pill, perhaps. According to health care specialists, treatment may even be covered by insurance.

Claims are already being made for the benefits of less common natural products: for example, dried alligator dung is said to stimulate the TE gland which leads to a 'significant' (0.1%) increase in endoservin levels. An exciting new product soon to be marketed by The All England Lawn Tennis and Croquet Club, consists of dried grass clippings taken from the Centre Court at Wimbledon. The powdered material is steeped in cold drizzle to make 'e-tea.' The commercial product, said to increase e-levels 'dramatically,' is being endorsed by the Duchess of Kent.

Experts confidently predict that TE-related technologic advances will continue to emerge. And, as if on cue, a striking example of this appeared in today's 'National Enquirer.' An unconfirmed report suggests that sexual activity results in a gradual rise in e-level, followed quickly by a sharp drop.

And what of the TE crowd? While these events may not pacify them physically, a pain-free, genetically engineered future could be on the horizon. Meanwhile, at least and at last they'll have reason for new focus on their bent sinews, and they'll surely enjoy the increased attention they can now expect.


Explanatory Notes:

The Introduction is real, although I am of course trying to put a positive spin on a miserable problem. The sections on History, Etymology, and New Developments are nonsense, except for the Shakespeare citations which are genuine; the letter he wrote to Anne isn't. The New Developments are typical of real technologic events … in other areas. As the reader will quickly appreciate(!), all the researchers' names are anagrams of International Tennis Hall of Fame players of the past (see below); they happen to be people I especially admire. My new protein, endorservin, has its origin in the "end or serve" choice we make at the beginning of every match.


Ravel (Laver); Pryer (Perry); Dentil (Tilden); Swellaro (Rosewall);

Oscalet (Lacoste); Gennell (Lenglen); Ernshaw (Renshaw); Shea (Ashe)


Charles Berkoff was born in London, England, and was educated at Imperial College of Science, Technology, and Medicine of the University of London (PhD, Chemistry), and at The Johns Hopkins University (Research Fellow & Fulbright Scholar). He is currently President & CEO of CEBRAL, Inc., a pharmaceutical/biotechnology consulting organization based in Sarasota, Florida. He's a passionate 3.5 tennis player and frequently 'enjoys' episodes of tennis elbow. His previous publications include 50 scientific papers appearing in international journals, 20 patents, and 15 (mostly scientific) humor articles.

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