yogabook / pathologie / Golfer’s elbow

Golfer’s elbow (epicondylitis ulnaris/medialis) / thrower’s elbow

Definition

Some authors equate Werferell’s elbow with Golferell’s elbow, but this is not necessarily correct, as Werferell’s elbow is usually described as ligamentous instability at the medial elbow. In contrast, golferell’s elbow is an insertional tendopathy (enthesiopathy) of the forearm flexors arising from the medial humeral epicondyle or the pronator teres: aseptic-inflammatory or degenerative process at the origins of the pronator teres. pronator teres, M. palmaris longus, M. flexor carpi ulnaris, depending on the source, the M. flexor carpi radialis and the M. flexor digitorum superficialis are also specified. The M. flexor carpi radialis is the most affected muscle.

Three types of golfer’s elbow can therefore be defined depending on the movement affected and therefore the muscles involved:

1. forearm pronationgolfer’s elbow: the pronator teres is affected
2. Wrist joint-palmar flexion-golfer’s elbow: M. flexor carpi ulnaris, M. flexor carpi radialis or M. palmaris longus are affected
3. Finger flexorgolfer’s elbow: the M. flexor digitorum superficialis is affected

Of course, mixed types can also be present.

The distinction between golfer’s and thrower’s elbow also results in different prognoses and treatment. While the golfer’s elbow can hardly be treated conservatively in the long term (muscle development can only insufficiently compensate for the ligamentous insufficiency), the golfer’s elbow is almost exclusively treated conservatively, especially in acute cases (less than 6 months). Golfer’s elbow is a not uncommon overuse syndrome. Initially swelling of the connective tissue, later tendon remodelling with collagen remodelling, cell proliferation and accumulation of substance P, a pain-mediating neurotransmitter and prostaglandin E2, a substance that sensitises the nociceptive nerve endings, among other things.

In addition to overuse, the factor valgus stress of the elbow joint can also play a role. The condition is very similar to tennis elbow. If there is not enough time to repair tissue damaged by microtraumas, degenerative changes occur. The collagen fibrils restructure and lose their parallel alignment. Angiomyofibrolastic proliferation, neovascularisation and infiltration of myofibroblasts are also found here. Calcification of the tissue is sometimes observed. Here, too, there is usually no inflammatory process, which is why the term epicondylitis is also out of place here; it would be better to call it epicondylopathy. If the disease has an inflammatory component, this is at best at the beginning of the acute phase. The flexors attach together with the pronator teres tendinously to the anterosuperior epicondylus humuri ulnaris, this tendon is known as the medial conjoint tendon MCT. In the immediate vicinity of the MCT is the insertion of the anterior portion of the medial collateral ligament, which is also known as the AOL, anterior oblique ligament. At three to four per thousand, the prevalence is 7 to 10 times rarer than that of tennis elbow. Here, too, there is an accumulation in later years of life, from the third to fifth decade. However, men are affected twice as often as women. The dominant arm is usually affected, in around 60% of cases. Only 30% of cases are due to trauma, the rest are overuse-related. Activities that generate algus stress in the elbow joint increase the likelihood of developing the disease and its severity. Half of the cases occur in the context of occupational activities; various tradespeople and assembly line workers are among the most frequently affected occupational groups; leisure activities and sports account for only 10 to 20% of cases. Among the sports that cause it are baseball, football, javelin throwing, bowling, tennis, swimming and golf, the latter in particular because inertia causes algus stress both during the acceleration of the hitting arm and when the club hits the ball. A sulcus ulnaris syndrome can occur as part of the Golfer’s elbow, which requires surgical release in 20 to 24% of refractory cases. The classification according to Gabel therefore distinguishes between

1. without sulcus ulnaris syndrome
2. Moderate sulcus ulnaris syndrome
3. Severe sulcus ulnaris syndrome requiring care

There is medial epicondyle pressor tenderness, as well as in the tendon tissue up to 10 mm distal to it. There is strain tenderness with wrist palmar flexion or stabilisation against dorsiflexing moments as well as stretch tenderness. Depending on the exact severity, pronation is also painful. The extension of the elbow joint may be noticeable in the behaviour of those affected. In 90% of cases, strain pain is detectable with pronation, in 30% of cases palmar flexion of the wrist. The pronation is then painfully restricted, which is clearly recognisable in the lateral comparison – taking into account the lateral dominance. In principle, a mild flexion contracture, i.e. extension deficit, is possible. Baseball pitchers are most frequently affected. A valgus stress test or milking test must be performed to test for insufficiency of the medial collateral ligament. For a possible sulcus ulnaris syndrome and should at least look for a Tinel’s sign and test whether hyperextension of the elbow joint exacerbates the pain or symptoms. In addition to the elbow joint, the shoulder joint and cervical spine should also be examined. A tendency to subluxation of the shoulder joint can exacerbate golfer’s elbow symptoms, resemble thoracic outlet syndrome and radiculopathies resemble sulcus ulnaris syndrome. 18% to 25% of patients show soft-tissue calcifications or osseous protrusions (osteophytes) on the medial epicondyle, which are not prognostically relevant. If valgus instability, i.e. medial gapping is known, imaging can be performed in both positions. Sonography detects epicondylitis with 95% sensitivity and 92% specificity. MRI also achieves high values and visualises the soft tissue very well, including partial and complete ruptures. It should also show changes in the medial epicondyle, the medial collateral ligament or in the humuroulnar joint.

If the acute event is still easily reversible, a self-reinforcing vicious circle of pain, incorrect loading and tissue changes can form if it becomes chronic, which can also lead to pain at rest and night pain. In contrast to RSI, slightly less frequent but significantly heavier movements are triggering here – in RSI these can be: typing on the keyboard or mobile phone, clicking the mouse … Peak 35-50th year.

In people whose elbow joint can crack, in the sense that a small movement triggers a clearly audible crack, but the next identical movements for a longer period of time do not, there is probably a small subluxation in the elbow joint. The cracking is then the sound sensation triggered by the reposition. In this case, the non-repaired condition may show increased pain (tense rest pain and pain on movement or pain on exertion) of the muscle origin affected by the golfer’s elbow.

ICD M77.1

Cause

1. Prolonged pressure (elbow support) creates microlesions and inflammation
2. Mechanical trigger: muscular overload causes microlesions, e.g. in golfers or often manual labourers, in sports also: incorrect technique

Predisposing

1. Insufficient training and stretching condition
2. Frequent tight gripping, frequent twisting movements of the forearm under load
3. racket sports (racket sports) especially with technical errors, climbing, various manual activities, physical work such as road construction, craftsmen, mechanics
4. Side sleeping with strongly bent arm as headrest

Diagnosis

1. Medical history
2. Palpation: induration, hypertonicity, localised pressive tenderness
3. Increased/earlier tenderness with dorsiflexion of the hand and fingers
4. The diagnosis can usually be made based on the medical history and examination
5. If necessary, X-ray to rule out fracture sequelae; in the chronic stage, may show calcification foci on the tendon; if necessary, sonography: shows swelling; if necessary, MRI
6. Tests and signs: Reverse Cozen test (testet Handgelenkpalmarflexoren), Medial epicondylitis test (testet Handgelenkpalmarflexoren), Pronation des Unterarms gegen Widerstand (testet das Caput humerale des Pronator teres), Palmar flexion des Wrist gegen Widerstand (testet Handgelenkpalmarflexoren), Heben schwerer Gegenstände im Underhand grip (testet Handgelenkpalmarflexoren), Ellbogenstrecken in supination bei passiv dorsiflexed wrist, definite yoga golfers elbow test cluster

Symptoms

1. Sharp elbow pain on the inside, which intensifies when closing the fist and (palmar) flexion (especially against resistance) in the wrist as well as when lifting, possibly radiating, especially into the forearm
2. Painful pressure of the epicondyle
3. möglicherweise geringe Schwellung
4. schmerzhafte Kraftminderung der betroffenen Muskulatur

Komplikationen

1. Kubitaltunnelsyndrom (auch: „Sulcus-ulnaris-Syndrom“, Nervenwurzelkompressionssyndrom des N. ulnaris im Sulcus ulnaris)
2. Chronifizierung mit Ruhe- und Nachtschmerz und starkem Schmerz bei kleinen Auslösern

Therapie

1. kurzfristige Ruhigstellung (langfristige kann Rezidivfördernd sein), Abbruch/Vermeidung der auslösenden Belastung
2. Kräftigungstraining (HSR, Heavy Slow Repetitions); im rehabilitativen Training (im Gegensatz zu Sport und Alltag) darf bis NRS-3 oder sogar NRS-5-äquivalenter Schmerz verspürt werden, wenn die Schmerzen binnen 24 h abklingen und nicht über die Übungseinheiten mehr werden
3. ggf. Lokalanästesie
4. ggf. lokale Kortisoninfiltration
5. Injektionen mit körpereigenen Wachstumshormonen oder Botox
6. Querfriktionen
7. NSAR
8. Elektrotherapie (TENS: transcutane elektrische NervenStimulation)
9. Kryotherapie
10. extrakorporale Stoßwellentherapie
11. Dehnung (wichtig !)
12. Physiotherapie nach weitgehendem Abklingen der akuten Schmerzen
13. im Akutstadium Kühlen (Eis nicht direkt auf die Haut !)), später Wärmen der Muskulatur
14. Epicondylitisspange
15. Bei Ruhigstellung: Ellbogen aussparen !
16. selten: OP (Querinzision, Längsinzision, Denervation), neuerdings auch mit Anbohren des Knochens bis ins Mark zwecks Einwanderung von Stammzellen in die Heilungszone
17. die Kombination mehrerer Therapien ist i.d.R. erfolgreicher als die Einzeltherapie
18. präventiv/rezidivprophylaktisch: Dehnung der Flexoren; vor Belastung dehnen, nach Belastung mit Eis kühlen; Bei Sport: Technik optimieren; Heben wo möglich vermehrt mit Obergriff (Vorsicht: Epicondylitis humeri radialis-Gefahr !); Kräftigungstraining (vorzugsweise HSR, heavy slow repetitions)

NHK

1. Acupuncture
2. Massage (cross-friction)
3. Leech therapy
4. Kinesiotaping
5. Homeopathy: Arnica, Ruta, Bryonia etc.

DD

1. Bursitis
2. osteoarthritis
3. tumours
4. Cervical syndrome
5. Fibromyalgia
6. Supinator ligament syndrome, pressure pain in the elbow more on the radial side (compression syndrome of the radial nerve)
7. Pronator-teres syndrome, pressure pain in the elbow more ulnar (compression syndrome of the median nerve).

Asana practice and movement therapy

As with all insertion tendopathies, care must be taken here to ensure that the pain is not triggered, as any triggering of the pain can disrupt the healing process and thus be likely to perpetuate the pain phenomenon. The rehabilitative strengthening exercises described in the yoga book are an exception. These are
for the type forearm pronationgolfer’s elbow: practising supination and pronation of the arm
and for the types wrist-palmarflexion-golfer’s elbow and
finger flexion-golfer’s elbow: palmar flexion and dorsiflexion of the wrist practice, for wrist palmar flexiongolfer’s elbow, possibly also practising radial abduction and ulnar abduction,
which are among the most important therapeutic measures. It is therefore very helpful to test for extension pain and strain pain to find out which type or mixed type of golfer’s elbow is present.

In the exercises described, the procedure described there can be used in deviation from the general rule of strictly avoiding the pain in question, in which the development of the pain that occurs is observed for 10 to 30 seconds in isometric contraction. If the pain subsides noticeably during this interval, this can be practised up to three times a day, while the majority of the rehabilitative training should be carried out with little to no pain

An intensive head up dog position or head down dog position as well as their transitions would generally be very suitable triggers. Therefore, the palmar flexors of the wrist and the finger flexors must not be used to push the body backwards. This applies analogously to many other postures: what is otherwise desirable, namely creating stability and intensity of the posture from the forearm muscles and working them as fully as possible, must be avoided here because they or their insertion is too vulnerable for this.

Complete pronation of the arm may also have to be avoided. Instead, it is better to perform functional strengthening exercises that are easy to scale. These are mainly various exercises with dumbbells such as bicep curls or palmar flexion. In addition, it is important to check the stretching status and tone of the targeted muscles, for which the forearm stretch palmar and the forearm stretch palmar in upavista konasana are excellent. In the former, the elbow joint is flexed and becomes more flexed as the pose progresses; in the latter, it is continuously extended, which allows for a more intense pose, as the targeted muscles proximal to the elbow joint attach to the medial epicondyle of the humerus (hence the name), the position of which is therefore relevant to the extent of the stretch. The pain sensation at the insertion at the epicondyle should only be approached up to the pain threshold; the muscle heads themselves may of course report intense stretch sensations. If it becomes apparent that the pain at the epicondyle occurs in both postures when performed with flexed fingers (palm on a block, fingers free) at a greater angle of dorsiflexion of the wrist, this is a sign that the flexor carpi ulnaris is being stretched. flexor carpi ulnaris is largely responsible (although not necessarily solely) for the pain phenomenon.

Arm balances, the stability of which depends on the finger flexors both when performed correctly without „mouse holes“ and when performed incorrectly, should be avoided as long as the epicondylitis persists. The leaning handstand and the right-angled handstand can be performed without any problems if the affected muscles are not used. In the case of the handstand upswing, however, it is one of the important muscles that limit the movement of the shoulder towards the wall. The handstand is therefore unlikely to be suitable for the less experienced, as it may be very difficult to find a level of use of the affected muscles that allows the movement of the shoulder towards the wall to be sufficiently limited and, on the other hand, does not trigger the epicondylitis pain. The elbow position, on the other hand, can be performed without any problems or restrictions. The ardha vasisthasana and vasisthasana are more difficult, as stability depends largely on the muscles involved. Both postures, and vasisthasana even more so, should probably be avoided for a longer period of time.

Asanas

1. Forearm stretch palmar
2. Palmar forearm stretch in upavista konasana
3. Practising supination and pronation of the arm