Tennis elbow

Synonymous

radiohumeral epicondylitis, lawn tennis arm, Epicondylitis humeri lateralis / radialis, mouse elbow

Definition

If one uses the expression "tennis elbow", almost everybody knows which pains are meant. From a medical point of view it is about a pain syndrome whose origins are located in the area of the hands` and also fingers` musculature and at the outer insertions of the upper arm bone (humerus). Therefore a so-called inflammation of the tendons` insertion (=tendonitis of the insertion), at which mainly the stretching musculature of the forearm is concerned, is meant by a tennis elbow. The inflammation is usually caused by an overstraining during the occupation or also during sports (e.g. tennis). This explains the origin of the name "tennis elbow".

Summary

The tennis elbow (Epicondylitis humeri radialis) is a localized inflammation in the area of the stretching musculature of the forearm and the hand. From a medical point of view it is about a so-called epicondylitis (humeri radialis).

On the one hand it is part of the tendopathy of insertions (= illness of the tendons, tendon sheaths and ligaments), on the other hand it is also part of the myotendinosis (illness of the unity of muscle = myo and tendon = tendo). Therefore the epicondylitis (humeri radialis) is an illness of the tendons and ligaments under participation of the adjacent musculature.

Tendopathies (= tendon inflammations) can possibly cause painful changes at tendons in the area of a muscle origin, at the insertion of muscles, ligaments or capsule. A tendopathy can therefore appear almost within the entire body.

When you suffer a tennis elbow due to overstraining your musculature characteristic pain occurs, which might possibly limit the ability to use the arm tremendously. The tennis arm occurs to men and women in about the same ratio and the same years of age, namely in the middle ages.

The tennis elbow can be treated both conservatively and operatively.

Usually you try to treat the syndrome conservatively at first. This implies methods of treatment such as:

• immobilization / fixation
• electromechanical stimulation
• cortisone injections
• ointment
• bandage
• shock wave therapy
• medical treatment

If the conservative methods do not work out, an operation can become necessary. For that purpose the muscles, which are needed for stretching the arm ("extensors of the forearm") will be loosened by notching the tendons` insertion.

General

There are different groups of muscles, which have their origin in the area of the elbow. These are muscle groups of the arm, the finger and the hand, among other things the Musculus extensor carpi radialis longus and brevis, the Musculus extensor digiti minimi and the Musculus extensor digitorum (= Musculus extensor digitorium communis), all so-called extensors of the forearm.

All muscle groups, which have their origin at the elbow, are connected to the elbow bone with the help of connective tissue structures (tendons) in certain places. While the largest part of the bending musculature is located on the inside (= ulnar side) of the elbow, the opponents, the so-called extensors (stretching musculature) are located on the outside (= radial side). Caused by a professional and / or sportive overstraining of the muscle groups an epicondylitis of the humerus can appear. It is a paraphrased pain syndrome in the area of the elbow. One distinguishes the epicondylitis humeri radialis from the epicondylitis humeri ulnaris depending on which musculature is concerned. An overstraining of the muscle groups on the outside, that is the hand and finger stretching musculature on the side of the thumb, can cause the appearance of the so-called epicondylitis humeri radialis (= tennis elbow).

In cases in which the muscle groups of the little-finger-sided hand and finger flexors are being overstrained, one talks about an epicondylitis humeri ulnaris, the so-called golfers elbow.

The name epicondylitis always implies an inflammable or degenerative (wear-related) change at the tendon insertion at the bone.

Inflammable scar tissue, which causes the pain, builds up in the area of the muscles` insertion.

Frequency

Usually more men than women suffer from the tennis elbow, one of the most frequent illnesses in the orthopedic branch. The average age of falling ill with the tennis elbow is between 35 and 50. 50% of all tennis-players fall ill with the epicondylitis humeri radialis in the course of their life. Every second tennis-player suffers from a tennis arm in the course of his / her life. The illness maximum among tennis-players is around between 50 and 60.

Causes

As already mentioned, the name "tennis elbow" does not mean that only tennis-players or athletes suffer from this illness. The "tennis elbow" actually only occurs quite seldom among athletes, as a rule only if a wrong technique is used, particularly when playing the tennis backhand.

Since the tennis elbow is caused by chronical mechanical overstraining, craftsmen, mechanics, street and construction workers or secretaries are much more frequently concerned with this. These occupational groups who use the computer as a means of work are also generally concerned. Within the last few years, the increasing use of particularly the computer mouse led to an increasing number of patients who suffer from a tennis arm. Additionally, notice the literature recommendation on diagnosis mouse arm.

Painful wear-out illnesses appear in the insertion area of the stretching musculature, which is concerned far more frequently than the antagonists, the so-called flexing musculature in the wrist.

Also older patients frequently suffer from a tennis arm in which the pains often can be explained by the individually different degenerative (arthritic) changes within the elbow joint.

The reasons for the appearance of an epicondylitis are not cleared obviously after the present state of knowledge yet. A permanent overstraining can lead to inflammations and tears within the tendons, on patients with a corresponding disposition, so-called predisposed patient. The mainly used arm is tendentious rather affected by the overstraining. Overstraining often occurs at very one-sided and monotonous activities which are permanently repeated.

Symptoms

The patient suffers from pain in the elbow area which usually radiates up to the hand, too. As a rule, a local stabbing pain on palpation at the bone insertion of the concerned musculature, as well as pains on the outside and inside of the elbow, which are evoked by rotations or by closing the fist. Also by a maximum turn of single muscles the symptomatology of pain can be strengthened.

Because of the pains the patients get restricted tremendously in carrying out their everyday activities. In the beginning they can only be performed with difficulty, later on the everyday activities can hardly be carried out at all. The simple handshaking as a welcoming ritual can already arouse maximum pains.

In further advanced stages it comes to the reduction of strength of the complete hand and finger musculature, which can lead to a complete loss of the entire strength of grasping.

Diagnosis

Due to the severe, sometimes stabbing pains, which more and more frequently appear when performing everyday activities and are partly so severe that carrying simple objects alone becomes tormenting, the patient goes to see a doctor. Patients frequently also complain about the pain radiating up to the forearm musculature.

In the context of the medical examination the doctor runs so-called resistance tests. The patient must make a fist and push up or down against resistance. At an illness of the tennis or golfer elbow the resistance test shows pain reinforcement within the elbow joint.

When putting pressure on the origin zones of the Musculus extensor digitorum communis and the Musculus extensor carpi radialis brevis, a severe, stabbing pain appears. Due to the pains of the patient one finds a movement restriction of the elbow joint again and again, too. This can be explained by degenerative (wear-related) changes only in quite rare cases though and is rather due to the resting position of the patients` arm.

Most of the times the complete forearm musculature is strongly tense and there can possibly also occur slight disturbances of sensation, which manifest themselves by a prickling, for example. As a rule, they are not caused by a cervical syndrome (cervical tension syndrome) or local nerve damages.

At the clinical examination a severe pain of palpation and tenderness to touch has to be aroused on the morbid tendon. Due to the pain, a restriction of movement in the elbow joint is found, which is, however, quite seldom triggered by degenerative / wear-related changes.

When doing an ultrasound scan the doctor can recognize a swelling in the area of the tendons` insertion, whereas at an x-ray examination of the elbow joint pathologic changes can only seldom, and mostly in farther progressed stages, be found.

In the chronic stage calcification herds in the area of the tendon insertion or little irregularities of the periosteum (periosteum irregularities) as well as outgrowths of the bone can be seen on the X-ray.

The doctor must distinguish between for example the epicondylitis humeri ulnaris (golfers elbow) and the epicondylitis humeri radialis (= tennis elbow) but also other illnesses and also exclude others. Therefore, he must be able to differentiate typical pains of the tennis elbow described above, from the ones of the neck spinal column (cervical syndrome). He must as well differentiate limitations and irritations of certain nerves (nerve compression syndrome > ramus profunds of the nervus radialis in the so-called supinatorgap), degenerative joint changes (arthritis) as well as acute local inflammation processes and tumors.

To distinguish whether the patient suffers from a tennis arm or a golfer elbow, the following tests will help the physician.

Tests

Epicondylitis humeri radialis (tennis arm / elbow)

Pain in the area of the outer elbow caused by:

• Turning the forearm
• Stretching the wrist against resistance
• Stretching the middle finger against resistance
• Stretching the elbow and passive flexion/ bending of the hand

Epicondylitis humeri ulnaris (golfer elbow)

Pain in the area of the inner elbow caused by:

• Flexion / bending of the wrist
• Turning the forearm against resistance
• Lifting up heavy things
• conservative therapy

Conservative therapy

Physical therapy

• Cold and heat treatment
• Localized Ultrasound treatment
• microwave
• iontophoresis
• Crossways massage of the wrist musculature

Medicinal therapy

Ointment bandages (partly Cortisone creams, Diclofenac-Emulgel etc.) Infiltration of the muscle insertion with an anti-inflammatory and pain-killing medicine (local anesthesia and corticoid mixtures)

Forearm plaster bandage

They are recommended at alternative conservative therapies, therefore at troubles continuing to exist. The forearm plaster bandage should, however, represent only the last alternative in the area of the conservative therapy

Epicondylitis clasp

It relieves the muscle insertion at the elbow and is carried prophylactically in the everyday and working life. The bandage must be used correctly (attach to the right place, ...)

Physiotherapy

Therapeutic exercise and stretching exercises

Especially for tennis-players:

Note on correct techniques, if necessary through (renewed) coaching sessions.

Slow training reconstruction

Warming up the muscles consistently and stretching the muscles

Change the racket possibly, for example by using a more flexible not so racket, which is not too heavy in the front

I mandatory recommend the adjustment of the strings on your racket (e.g. pre-extended vibration absorbing strings (there are special strings for players who suffer a tennis arm)) to every performance-orientated tennis-player or hobby players in combination with coaching sessions of a sports doctor / orthopedist with a tennis coach license.

Acupuncture

The acupuncture has proved itself here in many cases. On the one hand, it serves the pain relief, on the other hand, it can also stop the inflammation process, if the person stops the pain-producing activity, such as playing tennis. Unfortunately, this is not always possible, particularly in cases where the activities, which are causing the pain, are part of everyday life.

Extracorporeal shock wave therapy

In the context of the extracorporeal shock wave therapy ultrasound impulses are conducted on the painful tendon insertions. It is about one specific ultrasonic apparatus which is similar to an apparatus, which destroys kidney stones.

Success occurs approximately with 80% of all patients, there might be some complications during the treatment, though. Examples for those complications are: pain in the area of the epicondyles, as well as bruises due to injuries of small blood vessels.

Further therapies

Further therapy forms are:

• The magnetic field therapy and
• The pulsating signal therapy
• Till now, an obviously positive effect could not scientifically be ascribed to both therapy forms yet.

Operative therapy

Should there still be no recovery or even deterioration noticeable after an approximately six-month conservative therapy, it is to recommend thinking about an operative therapy together with your attending doctor.

Regarding this two different operation methods are available, on the one hand the operation developed by Hohmann, on the other hand the operation developed by Wilhelm. Both operation methods are described below.

Operation developed by Hohmann: This operation is named after a Munich orthopedist, who lived from 1880 to 1970. With regard to an epicondylitis, this kind of operation implies a separation of the corresponding musculature, which extends or bends the wrist. This leads to a relief of the tendon insertion and to a curing because of a scarred prolongation of the muscle insertion.

At first the surgeon puts a longitudinal section, which is only a couple of centimeters long, above the elbow bone. Pain leading fibers will be divided and another section is put between the extending musculature of the forearm. Finally, the tendon insertions will be divided at the outer elbow bone, so that the tension is relieved in this area.

Operation developed by Wilhelm: At this operation the surgeon divides those nerves which provide the elbow area. One also describes this operation as a so-called operation of denervation. To relieve the tendon insertion, there will – just like in the case of the operation developed by Hohmann – additionally be made a separation of the muscle insertions (combination with Hohmann - operation).

This operation form especially is being taken into consideration, if the pains radiate into the forearm. It is important to start with finger movement exercises immediately after the operation, which additionally can be supported by an active movement.

Forecast

The forecast can be considered to be good and successful since most patients, who suffer a tennis elbow can be healed conservatively, i.e. healed without an operation being necessary.

However, it might happen that the illness appears over a long period of time and can only be taken care of and healed by operating the arm. In rare cases even an operation can also not cause any durable relief of the pains.