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Ergonomics
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The prevalence and causation of tennis elbow (lateral

humeral epicondylitis) in a population of workers in an
engineering industry
a
LENNART DIMBERG
a
Volvo Flygmotor AB, 461 81 Trollhattan, Sweden
Published online: 06 Jul 2010.

To cite this article: LENNART DIMBERG (1987) The prevalence and causation of tennis elbow (lateral humeral epicondylitis) in
a population of workers in an engineering industry, Ergonomics, 30:3, 573-579, DOI: 10.1080/00140138708969746

To link to this article: http://dx.doi.org/10.1080/00140138708969746

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 The prevalence and causation of tennis elbow
(lateral humeral epicondylitis) in a population
of workers in an engineering industry

Volvo Flygmotor AB, 461 81 Trollhittan, Sweden

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Keywords: Lateral humeral epicondylitis; Tennis elbow; Work stress; Prevalence;

Industrial workers.

Lateral humeral epicondylitis (tennis elbow) is often considered to be work related

but the incidence and prevalence among industrial workers has not previously been
studied.
In this study the prevalence of this condition and its relationship to some work
factors was investigated in 540 workers in a modem engineering industry.
The prevalence was 7.4% (40/540). Work was found to be the probable cause in
35%, tennis in 8% and other leisure activities in 27% of the patients. No cause was
found in the remaining 30%. There was no correlation with sex, while a significant
correlation was found with age, the incidence increasing with advancing age.
On the basis of job classification according to their elbow stress, it was found
that these workers with work-related epicondylitis had higher elbow stress jobs
compared to other sufferers and to the workforce as a whole.

1. Introduction
Lateral humeral epicondylitis (tennis elbow) is considered to be caused by over-
exertion of the extensor muscles bf the wrist and has been said to be work related in up
to 74% of cases (Goldie 1964).The disease can produce long-lasting and severe medical
consequences and may need surgery. It may lead to economic consequences: sick leave,
workers' compensation claims, transfer to lower-paid jobs, and even early retirement. It
is therefore important to document frequency and causation. In a previous study
(Dimberg, 1983), we found that the condition was related to work in about
50% of a group of patients who had been seen by the company physician. But that study
did not aUow any conclusions to be drawn regarding prevalence. The aim of the present
study was to investigate prevalence and relate it to certain factors at work in a
manufacturing industry.

2. Material and metbods a

A q u e s t i o ~ a i r was
e distributed to every fifth person in the company's personnel file
selected by random numbers to provide a representative sample of all employees. The
sample consisted of 571 workers. Twenty-five were excluded as they were away
studying, on military service, or were pregnant. This left 546 subjects, 494 men and 52
women, ip the final questionnaire sample. The questionnaire contained items on elbow
pain (figure 1). Information was also collected on age, sex, causal factor ('Do you
suspect any particular activity to have started the symptoms?), present job, tennis
playing, and visits to physician for elbow problem. All workers who replied that they
had elbow problems were examined by the company physician (LD).Only those with a
confirmed'diagnosis were included in the analysis of those having lateral epicondylitis.
 L. Dirnberg

Name:

Employee No.

Depart men t:

Age:

Have you ever had elbow symptoms? Yes No

Have you had elbow symptoms since starting work at Volvo Flygmotof? Yes No
Have these symptoms been of the 'tennis elbow' t y p t e n d e r n e s s on the outside
of the elbow and pain during overhand grips, e.g. difficulty in holding a glass of
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milk? Yes No
Have you had 'tennis elbow' during the past year? Yes No
Have you had 'rheumatic problems' such as pain in muscles and joints? Yes No
Have you consulted the Company Medical Officer with elbow symptoms? Yes No
Have you been referred to another doctor by the Company Medical Officer? Yes No
Have you consulted any other doctor for elbow symptoms? Yes No
Have you consulted the Company Medical Officer during the past year for any
ailment at all? Yes No
Any other doctor? Yes No
What type of work have you had during the past year (turning, machine-setting,
typing etc.)?
Please return this questionnaire to the Medical Department.
Figure 1. Questionnaire on elbow symptoms from the medical department.

Lateral epicondylitis was defined by the following three criteria: lateral elbow pain,
pain on palpation over the lateral humeral epicondyle and pain-increase on dorsal
flexion (extension) of the wrist against resistance.
The number of employees at Volvo Flygmotot (Volvo Aircraft Engine Division) is
shown in table 1. The main products developed and manufactured by the company are
jet engines for aircraft, hydraulic pumps, and car components. Among white-collar
workers, the largest groups are production technologists, designers, typists and
computer operators. The working conditions for blue-collar workers varied greatly.
Some operations, performed by numerically controlled machines, required minimal
manual effort while others, like burring, grinding and welding, imposed heavy stresses
on elbows.
The jobs were classified into three groups with respect to elbow stress: type 1, Iow; 2,
moderate; 3, high (tables 2 and 3). The classification was made by the safety officer, a
physiotherapist and a physician (LD).

Table 1. Age distributions.

-19 2&29 30-39 4 0 4 9 5&59 60- Total

Men 10 111 124 102 92 50 489

Women - 14 16 14 7 - 51
Blue-collar workers 10 103 93 59 46 29 ,340
White-collar
workers - 22 47 57 53 21 200
Total 10 125 140 116 99 50 540
 Prevalence and chausationof tennis elbow in workers in engineering 575

Table 2. Classification into different types of jobs with respect to the patient's elbow stress.

No or little stress on the elbows Moderate stress on the elbows Heavy stress on the elbows
Data display operator Inspector Blaster
working with VDT (less
than 50% of the time) Electrician Driller
Driver Instrument maker Filler
Purchasing officer Repairman Burrer
Instructor Draughtsman Cleaner
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Instrument server Tempo worker Polisher

(Bearing brackets)
Designer Grinder
Unpacker
Office worker without Welder
regular typing Toolmaker
Tempo worker
Testing worker Data display worker (Cylinder linings,
working with VDT (more con'necting rods)
Security guard than 50%of the time)
Clerk Carpenter

Table 3. Distribution of respondents by type of work stress (1, low; 2, moderate; and 3, high).

Men
Women
Blue-collar 63 165 112
White-collar 165 33 3 ;
<40 years 89 118 68
5 4 0 years 139 80 46
Total 228 198 114

546 questionnaires were sent out in October 1982 and within one month, 540
(98.9%)were returned. Six people refused to fill out the forms despite telephone calls by
a nurse. None of these had been sicklisted because of elbow pain.
The differences in prevalence between subgroups were examined using, standard,
t wo-tailed normal approximation tests. Multiple regression was performed to study
the simultaneous influence of background factors on the prevalence.

3, Results
Of the 540 responders, 83 suffered from lateral elbow pain. Lateral humeral
epicondylitis was verified in 40 of them giving an estimated prevalence of 7.4%.
Epicondylitis occurred in the dominant arm in 38 cases (9573, and in both arms in 2
(5%). The prevalences for white- and blue-collar workers were 11.0 and 543%. The
difference was not statistically significant. Prevalence among older and younger
employees was studied. The prevalance in younger blue- and white-collar workers (up
to 40 years) was 4-6and 6.1 % respectively compared to 8.9 and 13.9%for those aged 40
 576 L. Dimberg .

and over. There was no statistically significant difference between the prevalences in the
two occupational groups.
Job classifications revealed that, in general, blue-collar and younger workers
experienced more elbow stress than white-collar and the older (table 3). There is no
evidence that those with epicondylitis had experienced greater elbow stress than the
totality of employees (figure 2). The proportion of workers who consulted a physician
for their elbow problems was significantly greater with increasing elbow stress
(P<0.05). Older individuals with high-stress jobs had a prevalence of 17.9% (7 out of
39).
Half of those with the condition had not sought medical advice but there was no
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indication that the severity of the disease differed between those who came to the
physician and those w h o did not.
Multiple regression analyses with the absence or presence of epicondylitis as the
dependent variable and sex, employee category, age and degree of stress as the
independent variables showed that only age was significantly related to prevalence. -. .

Ea proportion consulting a physician

Type 1 TYPC 2 Type 3 Type 1 Type 2 Type 3

E p i c o n d y l i t is- A l l cmployeee
ouf f crcrs
Figure 2. Distribution of epicondylitis sufferers, those who have consulted a physician for
elbow symptoms and all employees by type of work stress ( 1 , low; 2, moderate; and 3, high).
 Prevalence and causation of tennis elbow in workers in engineering 577

Over-exertion of the extensor muscles of the wrist due to gripping and twisting
movements prior to the onset of symptoms was verified in 28 (70%) of the sufferers and
in 27 of them the onset was sudden; virtually all affected the dominant arm. In 14 (35%)
the disease was considered to be caused by work, in 3 (8%) by playing tennis, in 11 (27%)
by other leisure activities and in 12 (30%) no cause was found. No particular job
dominated among the sufferers. House building and gardening were the most
frequently listed causal leisure activities, white-collar workers predominated in this
group. The difi'erences in levels of work stress between those citing work-related and 'no
known' causes is shown in figure 3. The proportion of tennis players among sufferers
was 15% and in the total population of workers 12%. Similar figures for all racquet
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sports were 20 and 15%.

4. Discussion
In this survey we diagnosed lateral epicondylitis in 40 out of 540 (7.4%). In more
than half of those reporting pain at the lateral side of the elbow the diagnosis of lateral
epicondylitis was confirmed. This ernphasizes'the importance of a medical examination
to verify questionnaire information pertaining to specific diagnoses in the musculo-
skeletal system. In a previous epidemiologic study on a general population, the
prevalence of lateral epicondylitis varied between different age groups from 2 to 19%
(Allander 1974). Surprisingly, the disease was equally common in white as in blue-collar

Lciourc r e l a t e d No known cause Work related

group . ~ r o Pu crow
Figure 3. Relative distribution of epicondylitis patients by causal groupfieisure-related group,
N = 14; no known causc group, N = 12, and work-related group. N = 14) and by typc of
work stress (I, l o y 2, moderate; and 3, high).
 L. Dimberg ,

workers, in spite of the higher mean age of the white-collar workers. It was clear that
most white-collar workers hadcontracted their problems while working on their house
or garden. This suggests that risks may be increased when doidg unusual tasks.
Workers with epicondylitis caused by factors at work do differ with regard to the type
of work which they habitually do; it is generally of higher stress when compared to
those unrelated to work (figure 3). This tends to confjrrn the work-related cause.
I t is also suggested in several studies (Runge 1873, Goldie 1964, Iltschevski 1976,
Penners et al. 1977) that the aetiology of lateral epicondylitis is over-exertion of the
extensor muscles of the wrist due to gripping and twisting movements. The sudden
onset, affection of the dominant arm and association to specific causal activities among
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most sufferers found in this study supports this hypothesis.

In recent studies, groups of-tennisplayers were investigated and no cause other than
tennis was asked for (Priest et al. 1980a, b). In our sample only a small proportion (8%)
gave tennis playing as the most probable causal factor and the proportion of tennis
players among the sufferers was similar to that in the total population. There is
therefore only weak support for tennis and other racquet sports being a major
aetiological factor. This is not to deny that lateral epicondylitis can be caused by tennis.
The difference in the proportion of those with the condition giving work-related
causes in our two studies (about one-third in the present and one-half in Dimberg
(1986)) may be explained by the fact that in the present study only half had sought
medical advice, while in the previous study only those who had gone to the company
physician were studied. Furthermore, the tendency to seek medical advice increased
with the stress of the job. This suggests that the condition makes performance of the
more stressful jobs even more difficult. This is also supportive for the validity of our
work-stress classification by type of work (table 2). It would, therefore, be helpful in the
work-stress classification in a large epidemiological study if a simple instrument could
give objective data on wrist and arm movements. Existing methods such as the
Posturegram system (Priel 1974), Owako Working Posture Analysis System (Kahm
et al. 1977), VIRA (Kilbom et al. 1985) and EMG-techniques (Jonsson 1981) are
awkward and too time-consuming for large-scale field application. -

5. Conclusion
In about a third of the 40 sufferers with epicondylitis, the disease was considered to
be caused by factors at work. One-third got their elbow problem through leisure
activities (including tennis in 8%) and in another third no cause was found. There was
no statistically significant difference between the prevalences in blue and white-collar
workers.
Proportionately more subjects with the condition caused by factors at work had
moderate and high elbow stress jobs compared to the other sufferers and to the
workforce as a whole, which tends to confirm the work-associated .cause.
The proportion of workers with epicondylitis who had seen a doctor for their
disease increased with increasing work stress.

Acknowledgments
The author whishes to thank Dr Bo Erikson for statistical advice, Dr Anker
Johannesen for diagnostic advice, Sture Karlsson, safety engineer, and Lars-G6ran
Josefsson for help with the work-station classification by type of work, and Gull-Britt
Sjoestrand and Christer Erkenborg for help in collecting data.
 Prevalence and causation of tennis elbow in workers in engineering 579

The author also wishes to thank Dr Per-Olof Hasselgren for advice on the layout of
the manuscript, Dr Gunnar B. J. Andersson for constructive criticism, and Marianne
Berlin for typing the manuscript.

L'kpicondylite lattrale (tennis elbow) est souvent considtrie comme itant d'origine
professionnelle, mais son incidence et sa frkquence parmi la main-d'oeuvre indwtrielle n'ont,
jusqu'a prbent, pas kti k t u d i h . Cette 6tude examine la frkquence de cette affection et sa relation
avec I'activiti professionnelle auprts de 540 travailleurs dans une entreprise moderne. La
frkquenw observee ltait de 7'4% (401540).Pour 35% le travail en itait probablement la cause, pour
8% c'etait le tennis, pour 27% c'etait d'autres activitk de loisir et pour 3W/, on n'a pas trouvi de
causes. L'affection n'btait pas corrklke avec le sexe, mais significativement avec 1'8ge, avec une
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frtquence croissante avec l'ige. Lorsqu'on se base sur une classification selon le type de travail,
on constate que les travailleurs presentant une Cpicondylite d'origine professionnelle ont plus
souvent une activitt ginbratrice de contrainte sur le coude que les autres personnes affect& et
que la main-d'oeuvre, dans son ensemble.

German abstract not available for publication.

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Manuscript received 31 July 1985.

Final revision received and accepted 3 September 1986.