pathology: Golfer’s elbow

yogabook / pathologie / Golfer’s elbow

Golfer’s elbow (Epicondylitis ulnaris/medialis) / Thrower’s bow

Definition of

Some authors equate Werferell’s elbow with Golfer ’s elbow, but this is not necessarily correct, as Werferell’s elbow is usually described as ligamentous instability of the medial elbow. Golfer’s elbow, on the other hand, is an insertional tendinopathy(enthesiopathy) of the forearm flexors arising from the medial humeral epicondyle: aseptic-inflammatory or degenerative process at the insertions of the pronator teres muscle, palmaris longus muscle, flexor carpi ulnaris muscle and, depending on the source, also the flexor carpi radialis muscle and flexor digitorum superficialis muscle.

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

  1. Forearm pronation golfer’s elbow: the pronator teres muscle is affected
  2. Wrist palmarflexiongolfer’s elbow: flexor carpi ulnaris, flexor carpi radialis or palmaris longus muscles are affected
  3. Finger flexor golfer’s elbow: the flexor digitorum superficialis muscle is affected

Of course, mixed types can also be present.

This also explains the different prognosis and treatment of golfer’s and thrower’s elbow. While the golfer’s elbow can hardly be treated conservatively in the long term (muscle strengthening can only inadequately 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 sensitizes the nociceptive nerve endings, among other things. If the acute event is still easily reversible, chronic pain can lead to a self-reinforcing vicious circle of pain, incorrect strain and tissue changes, which can also lead to pain at rest and at night. In contrast to RSI, slightly less frequent but significantly more severe movements are the trigger here – with RSI these can be: typing on the keyboard or cell 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 reduction. The non-reduced condition may show increased pain (tense pain at rest andpain on movement or exertion) in the muscle origin affected by the golfer’s elbow.

ICD M77.1

Cause

  1. Prolonged pressure (elbow support) causes micro-lesions and inflammation
  2. Mechanical triggering: muscular overload causes microlesions, e.g. in golfers or often manual workers, in sports also: incorrect technique

Predisposing

  1. Insufficient training and stretching condition
  2. Frequent firm 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 a strongly bent arm as a headrest

Diagnosis

  1. Medical history
  2. Palpation: induration, hypertonicity, local tenderness
  3. Increased/earlier pain on stretching during dorsiflexion of the hand and fingers
  4. The diagnosis can usually be made on the basis of 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, ultrasound: shows swelling; if necessary, MRI
  6. Tests and signs: reverse Cozen test (tests wrist palmar flexors), medial epicondylitis test (tests wrist palmar flexors), pronation of the forearm against resistance (tests the caput humerale of the pronator teres), palmar flexion of the wrist against resistance (tests wrist palmar flexors), lifting heavy objects with an underhand grip (tests wrist palmar flexors), elbow extension in supination with a passively dorsiflexed wrist, definite yoga Golferellbogen Test-Cluster

Symptoms

  1. Sharp elbow pain on the inside, which intensifies when closing the fist and(palmar) bending (especially against resistance) in the wrist as well as when lifting, possibly radiating, especially into the forearm
  2. Pressure pain of the epicondyle
  3. Possibly slight swelling
  4. Painful reduction in strength of the affected muscles

Complications

  1. Cubital tunnel syndrome (also: „ulnar sulcus syndrome“, nerve root compression syndrome of the ulnar nerve in the sulcus ulnaris)
  2. Chronification with pain at rest and at night and severe pain with minor triggers

Therapy

  1. Short-term immobilization (long-term immobilization can promote recurrence), discontinuation/avoidance of the triggering stress
  2. Strengthening training (HSR, Heavy Slow Repetitions); in rehabilitative training (in contrast to sport and everyday life), up to NRS-3 or even NRS-5 equivalent pain may be felt if the pain subsides within 24 hours and does not increase over the exercise sessions
  3. Local anesthesia if necessary
  4. Local cortisone infiltration if necessary
  5. Injections with the body’s own growth hormones or Botox
  6. Cross-frictions
  7. NSAIDS
  8. Electrotherapy (TENS: transcutaneous electrical nerve stimulation)
  9. Cryotherapy
  10. Extracorporeal shock wave therapy
  11. Stretching (important!)
  12. Physiotherapy after the acute pain has largely subsided
  13. Cooling in the acute stage (do not apply ice directly to the skin!), later warming of the muscles
  14. Epicondylitis brace
  15. When immobilizing: Avoid the elbow!
  16. rarely: Surgery (transverse incision, longitudinal incision, denervation), more recently also with drilling of the bone into the marrow for the purpose of migration of stem cells into the healing zone
  17. the combination of several therapies is generally more successful than individual therapy
  18. Permanent therapy/prevention: stretching the flexors, see also below in the „Asana practice and movement therapy“ section
  19. Preventive/relapse prophylaxis: stretch before exercise, cool with ice after exercise; during sport: optimize technique; lift more with an overhand grip where possible (caution: risk of epicondylitis humeri radialis!)

NHK

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

DD

  1. Bursitis
  2. Osteoarthritis
  3. Tumors
  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 insertional tendinopathies, care must be taken not to trigger the pain, as any triggering of the pain can interfere with the healing process and thus maintain the pain phenomenon. The rehabilitative strengthening exercises described in the yoga book are an exception. These are
for the forearm-pronation-golfer’s elbow type: practicingsupination and pronation of the arm
and for the types wristpalmarflexion golfer’s elbow and
Finger flexion golfer’s elbow: practise palmar flexion and dorsiflexion of the wrist, possibly also practisingradial abduction and ulnar abduction for wrist palmarflexiongolfer’s elbow,
which are among the most important therapeutic measures. It is therefore very helpful to first find out which type or mixed type of golfer‘ s elbow is present by testing for pain on extension and pain on exertion.

In deviation from the general rule of strictly avoiding the pain in question, the procedure described there can be used for the exercises described, 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 practiced up to three times a day, while the majority of the rehabilitative training should be carried out with little or no pain

An intensive upward dog position or downward dog position and 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 to create stability and intensity of the posture from the forearm muscles and to achieve their fullest possible work, must be avoided here, as they or their insertion are too vulnerable for this.

Complete pronation of the arm may also need to be avoided. Instead, it is better to perform functional strengthening exercises that are easily scalable. These are mainly various exercises with dumbbells such as biceps curls or palmar flexion. In addition, it is important to check the stretching status and tone of the targeted muscles. The palmar forearm stretch and the palmar forearm stretch in upavista konasana are ideal for this. In the former, the elbow joint is flexed and is flexed further in the course of the exercise; in the latter, it is stretched throughout, which allows for a more intensive exercise, as the targeted muscles are located proximal to the elbow joint on 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 on the epicondyle should only be approached up to the pain threshold; the muscle heads themselves may of course report intense stretch sensations. If it can be seen that the pain at the epicondyle occurs in both postures when the fingers are flexed (palm on a block, fingers free) at a greater angle of dorsiflexion of the wrist, this is a sign that the flexor carpi ulnaris muscle is mainly 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 less experienced people, as it is 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 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 difficult, as stability depends largely on the affected muscles. Both postures, and vasisthasana itself even more so, probably need to be avoided for a longer period of time.

Asanas

  1. Palmar forearm stretch
  2. Palmar forearm stretch in upavista konasana
  3. Exercisesupination and pronation of the arm