The elbow is a complex joint. The radius and ulna rotate around each other (pronation and supination), while the two bones of the forearm perform flexion and extension movements together with the upper arm. These three joint components are enclosed within a capsule and secured by ligaments.
Both tennis elbow and golfer's arm are caused by overstraining the hand muscles, which causes painful inflammation of the tendon.
These afflictions are generally caused by sporting activities, but also by monotonous movements such as when working on computers or other manual activities.
Typical movements such as gripping, carrying, or lifting objects become painful. Conservative treatment includes physiotherapy, stretching exercises, sports ointments, and wearing an elbow bandage. If symptoms persist, cortisone, autologous conditioned plasma (ACP), or shock wave therapy can also help.
Surgery should only be considered if conservative treatment has been unsuccessful.
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Tennis elbow is caused by overstraining of the hand and finger extensor muscles, which originate in the elbow. This results in a painful inflammation of the tendon attachment on the lateral side of the elbow, which is also called epicondylitis. Sporting activities, mostly an incorrect playing technique when playing tennis, trigger the symptoms of tennis elbow. It is astonishing for many of my patients that 80% of all cases of “tennis elbow” are not caused by tennis but by other types of sport – or even by repetitive movements when working with a computer, other hand activities or by excessive exertion at work.
The cause of the strain on the extensor muscles lies in the functional reversal of the long finger extensor muscles when fisting. When the fist, these long finger extensor muscles are in the middle joint of the fingers to flexor muscles. When gripping a tennis racket almost all muscles of the forearm are tense and thus operate in the sense of finger flexion (you can try it yourself and feel it on your forearm). If from such a position of the bias comes a hit on the tennis racket, then the flexor muscles can easily be stretched overloaded. The result is typical pain in the lateral elbow area (Tennis Elbow)
Tenderness in the lateral region of the elbow, sometimes in combination with a hardening of the tendons of the extensor musculature in the forearm is common. Typical movements such as gripping, carrying, or lifting objects become painful.
Other possible causes of pain must be evaluated and ruled out before a diagnosis of tennis elbow can be confirmed:
- Epicondylitis on the lateral side of the elbow (thrower’s or golfer’s elbow)
- Muscular hardening in the shoulder or neck that can radiate to the elbow
- Nerve pressure symptoms in the cervical spine (cervical disc prolapse) and the arm (sulcus ulnaris syndrome; supinator tunnel syndrome)
- Direct joint pain (e.g. caused by cartilage damage, loose bodies, etc.)
Sport salves (Note: the exact type of salve must be discussed with your doctor. Not every ointments called "sports salves" are actually suitable for treatment) must be used locally without fail, cryotherapy and cold compresses should be used at night during acute episodes. Moreover, repetitive arm movement must be changed. When playing tennis, a larger racket grip, reduction in racket tension, softer balls, and a correction of striking technique (positioning lateral to the ball) can all significantly improve symptoms. In the case of computer work, the position of the hand over the keyboard should be modified (wrist rest, desk height adjustment, angled keyboards etc.).
The following points are crucial for the successful treatment of tennis elbow:
- Consistent physiotherapy is crucial for successful treatment (iontophoresis, ultrasonic therapy, training of the upper arm and shoulder musculature to relieve the forearm muscles, cross frictions, etc.) and taking a break from sports all help, preferably in combination with analgesic and anti-inflammatory medication.
- Concentric and eccentric stretching exercises: The lateral forearm extensor muscles that are often in permanent contraction as a result of the pain can be stretched again very gently using stretching exercises. This should be continued once the patient is free of pain for a long period of time, in order to prevent another episode. Wearing a tennis elbow bandage below the elbow can also lead to a reduction in pain.
- Topical treatment with Diclofenac pain-relieving gel (for example, Voltado forte): Massage vigorously twice a day (don’t just pat it on).
- A tennis elbow bandage (Dr. Gäbler recommends EpiPoint Stabilorthese from Bauernfeind.) The bandage should be worn below the elbow, which reduces the pull on the forearm extensor tendons, giving the tendons a chance to recover by preventing excessive stress in everyday situations. When pain is acute, stress can be caused by something as innocuous as a handshake.
Cortisone injections are the last resort, and cortisone is very effective at inhibiting inflammation. Cortisone injections, however, are not without risk (see achillodynia). If two injections have no effect, further injections should be avoided to prevent the risk of deteriorating tissue or even causing tendon ruptures.
ACP - AUTOLOGOUS CONDITIONED PLASMA:
Autologous conditioned plasma (ACP) transfusion is a new method for treating chronic achillodynia and insertional tendinopathy. It has long been known that the growth factors contained in human blood can have a positive effect on various healing processes, and ACP is based on this knowledge. Concentrated growth factors in the blood can stimulate healing and growth processes in the damaged and/or inflamed tendon tissue.
How does ACP therapy work?
As during a blood test, a small amount of blood is taken from a vein in the arm. Next, a special centrifuge process is used to isolate the part of the blood that contains the body’s own regenerative and osteoarthritis-inhibiting components. The endogenous solution that results is injected into the affected tissue using a specially designed double syringe (Arthrex Double Syringe). This newly developed double-chamber system guarantees the sterile extraction and injection of the growth factors, ensuring the highest possible degree of safety. Note: There is still no scientific proof that this type of therapy is beneficial, or in what percentage of cases lasting healing is achieved. However, there are reports of positive outcomes following the use of ACP, particularly in osteoarthritis patients.
EXTRACORPOREAL SHOCK WAVE THERAPY:
Extracorporeal shock wave therapy is a newer method of pain relief that alleviates pain not through fragmentation but instead by activating the self-healing processes of the cell. Moreover, shock wave therapy improves cell metabolism and deactivates pain fibers. After multiple treatments, 60-80% of patients experience alleviation or even complete pain relief.
It should be noted that there is currently little scientific data on both ACP and EWST for treating tennis elbow. However, in clinical practice Dr. Gäbler often sees encouraging results, even after months of persistent discomfort. Before taking the extreme step of undergoing an operation, it is always important to consider every available treatment option!
Only once all conservative (non-surgical) treatment methods have been carried out consistently for six months and symptoms continue to persist should an operation (revision of the extensor carpi radialis brevis) be considered. A periostomy of the tendon attachment has indeed helped in many cases, however it also often leads to functional deficits. It has been shown that the primary cause of pain in tennis elbow is degeneration of the attachment of the extensor carpi radialis brevis muscle. This muscle lies under the aponeurosis of the extensor carpi radialis longus. During the operation, the superficial aponeurosis is split. This provides a good view of the degenerated and often broken tendon sections of the extensor carpi radialis brevis muscle. Damaged tendon sections must be surgically removed and the bone bed freshened up. Rapid pain relief is achieved in the majority of cases, however, a short period of postoperative immobilization and a three-month pause in sports (tennis) is advised.
Golfer’s elbow is also caused by overstraining of the musculature, however, it concerns the musculature that originates on the medial side of the elbow. This results in a painful inflammation of the tendon attachment on the medial side of the elbow, which is also called Epicondylitis (or medial Epicondylitis).
One-sided sporting overexertion is a trigger for the symptoms of golfer’s elbow. Treatment as in that administered for tennis elbow.
Bursitis is an inflammation of the bursa. The bursa is located on the posterior side of the elbow (there are also bursas in other places, all of which improve gliding functions, such as in the knee or shoulder for example). A typical swelling is at the elbow. The bursa is often swollen into a lump. In the acute stage, the bursa inflammation is very painful and the elbow is hot, a state termed acute bursitis.
The cause can be an injury from falling onto the elbow. Bacteria can enter the bursa through even a small laceration, leading to infection and inflammation. Immediate surgical removal of the infected bursa may be required. In less dramatic cases, immobilization in a cast and antibiotic treatment can suffice.
Mechanical overstimulation or blunt injuries can also lead to bursitis, which is referred to as chronic bursitis. This may not be as painful but is equally uncomfortable. Treatment consists of cryotherapy and cold compresses. If the pain is severe, the bursa can be punctured. This rapidly improves symptoms, however, the bursa often fills up with fluid again and additional puncturing is required. In the case of persistent symptoms, immobilization in a cast can be necessary and sometimes surgical removal is also required.
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