yogabook / pathologie / tennis elbow

Epicondylitis humeri lateralis / radialis / tennis elbow / tennis elbow

Definition

painful insertional tendopathy at the muscle origins of the wrist dorsiflexors and finger extensors at the lateral epicondylus humeri. In this respect, the term epicondylitis is misleading because the inflammatory component (which does not affect the tendon but is peritendinous) is usually less prominent than the degenerative component caused by a series of microtraumas, which is why some authors speak of epiconylopathy. As is often the case, it is said to be chronic after 6 months. The tennis elbow is a classic, frequently occurring overuse syndrome and is caused by cumulative strain, possibly with neurological irritation and metabolic changes: overuse of the muscles leads to hyperacidity up to muscle hard tension (like a permanent contracture) with the consequence of overstimulation of the tendons and periosteum and intratendinous necrosis.

Repeated overuse-related microtraumas therefore lead to degenerative changes and ultimately to structural damage with the possibility of complete failure in the sense of a rupture, partial or total. The tendon appears as shiny, oedematous scar tissue. Angiofibroblastic hyperplasia is accompanied by neovascularisation and migration of fibroblasts. Similar changes are also found after cortisone infiltrations close to the tendon. The changes at the CEO can impair joint stability and lead to posterolateral rotational instability PLRI, as can also be seen after surgery or after multiple cortisone infiltrations. The instability in turn overloads the stabilisers of the joint, in this case the extensors, and exacerbates what is happening at the CEO. In the case of a tennis elbow, PLRI must therefore be investigated. In addition to overuse-related primary causes, extensor lesions or collateral ligament lesions are also possible traumatic primary triggers.
Secondary causes include intra-articular pathologies such as cartilage damage, protruding plica, chronic instabilities such as PLRI in particular, repeated cortisone infiltrations, including those that damage the lateral collateral ligament, and surgery.

The most commonly affected muscles are extensor carpi radialis brevis and, to a lesser extent, extensor communis, but possibly also . also supinator and other wrist dorsiflexors such as extensor carpi radialis longus, extensor digiti minimi and extensor carpi ulnaris. The origins of the four extensors extensor carpi radialis brevis, extensor digitorum (communis), Extensor digiti minimi and Extensor carpi ulnaris can hardly be separated from each other, which is why the term CEO (Common Extensor Origin) was created for them.

The extensor digitorum (communis) is the most superficial and the extensor carpi radialis brevis is the most profound. The origins do not fuse with the lateral collateral ligament complex directly below. The underside of the extensor carpi radialis brevis moves on the lateral part of the capitulum humeri when the elbow moves. This means that repeated movements under load can cause damage to it. As the muscles mentioned primarily affect the wrist , overuse of the stabilisation of this joint or movement in this joint generally causes tennis elbow.

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

1. forearm supinationtennis elbow: the supinator muscle is affected
2. Wrist joint dorsiflexion-tennis elbow: extensor carpi radialis brevis, extensor carpi radialis longus or extensor carpi ulnaris are affected
3. Finger extensor tennis elbow: extensor communis or extensor digiti minimi are affected.

Of course, mixed types can also be present.

Among the affected muscles, the extensor carpi radialis brevis is the most commonly affected muscle. Regardless of which tendon is affected, the tight position of the tendons in a convex arc makes metabolism and healing/repair after overloading more difficult,
which leads to hyperplasia of less vital cells originating from the uppermost layer of the tendocytes. The term tennis elbow is very plausible in view of the stress caused by tensile forces that occur in the tendons of the wrist dorsiflexors at the lateral epicondyle when the tennis ball hits the racket during one-handed backhand play. The fact that golfers‘ elbow, as the counterpart of tennis elbow, occurs much less frequently in the palmar flexors as a result of forehand play is simply due to the fact that the palmar flexors are on average much stronger and more robust in humans. Some typical risk factors have also been identified outside of sport, see below. Epicondylitis is usually self-limiting, the acute phase usually lasts 6-12 weeks. Recurrences are not uncommon and worsen the prognosis, especially if stressful factors cannot be reduced. The prognosis is also worsened by severe pain, persistence of pain for more than 3 months and depression. Pathophysiologically, the tendon does not heal after stress, and angiofibroplastic hyperplasia occurs. There is also a risk of calcification.

The pain symptoms are located over the lateral epicondyle and just distal to it and usually creeps in. There is localised pressive tenderness over the lateral epicondyle and distally in the tendons. There are generally no functional limitations, apart from painfully limited use of the muscles and a pain-related lack of stability in the wrist. For the examination, provocation tests using stress, pressive pain and stretching are available, including the chair test, the Bowden test, the Thomson test and the Cozen test, as well as the middle finger provocation test (Maudsley test).
Mobility and strength tests should be carried out for the wrist and fingers. The lateral collateral ligament should be tested with the elbow joint extended and flexed 20°, both in supination and pronation of the arm. Sonography provides a good initial overview, while X-rays can at best be used to rule out bony changes such as avulsions, free joint bodies, calcium deposits and bone spurs, meaning that MRI is the imaging of choice. The distances determined with this can also be used to suspect PLRI if necessary. MRI can be used to differentiate between three degrees of severity, from tendon thickening and partial rupture to total or subtotal rupture. As in other cases, clinical and imaging findings can diverge.

For the time being, treatment is conservative. Various physiotherapeutic procedures are available, as well as various infiltrations. Short-term immobilisation can make sense, especially if it serves to increase compliance by giving the patient a better chance of avoiding or changing the previous stressful behaviour. The procedures mentioned have different and generally limited effectiveness. Stretching exercises can help with shortened muscles, but as a rule, slow, predominantly eccentric strengthening muscle training is the most promising measure, whereby it has been shown that a higher frequency can mean a better outcome.

Extracorporeal shock waves, acupuncture, magnetic field therapy, laser therapy and iontophoresis can also be used as an option, although there is insufficient evidence for these procedures. Unless contraindicated, NSAIDs should not be taken for more than two weeks. They act more on any inflamed synovial tissue and have an analgesic rather than an anti-inflammatory effect.
For tennis players, technique training, switching to two-handed backhand play are more helpful than a softer string and vibration dampers. Cortisone infiltrations only show short-term success, but have long-term risks in the form of increased risk of complications, including infections, atrophy of the skin, fatty tissue necrosis, altered pigmentation of the skin, tendon damage and collateral ligament damage. If they are undertaken, their number should definitely be limited to three. In principle, the disorder tends to heal spontaneously if the conditions are right, but the condition of the muscles should be improved in terms of stretching and strengthening to prevent recurrence; improvements in the ergonomics of activities and technical training in sport are also important. If surgery is performed in cases that are resistant to conservative treatment, moderate to severe pain persists in a quarter of cases after one year.

Epidemiology

In Germany, tennis elbow has an annual prevalence of 6% with a peak age between 36 and 58 years, 89% of which improve with conservative therapy. Only 4-11% undergo surgical intervention. According to other studies, 1-3% of the population suffers from it, with the physically active proportion more likely to be 7%. The annual incidence is around 4-7 / 1000. In a large-scale study, men and women were affected more or less equally, while other studies showed that women were more frequently affected.
The risk is increased by regular repetitive movements. Among tennis players, 50% are affected throughout their lives, and beginners with one-handed backhand technique are more frequently affected. Up to a duration of 6 months, tennis elbow is described as acute, thereafter as chronic.

See also the external link https://www.physio-mg.de/wp-content/uploads/Schneider2018_Article_DerTennisellenbogenTennisElbow.pdf

ICD M77.0

Cause

1. Overexertion, e.g. due to tennis, mechanical work (assembly line production), intensive playing of a musical instrument, housework, formerly also in stenotypists
2. Fluoroquinolone antibiotics (have a tendotoxic effect)

Predisposing

– Behaviour of the movement apparatus

1. various sports such as rowing, tennis, other racket sports
2. Various musical instruments such as the violin
3. intensive use of the computer mouse
4. screwing movements (e.g. tightening screws – loosening screws, on the other hand, could lead to golfers elbow)
5. Handling weights of at least 20 kg at least 10 times a day
6. frequent daily handling of tools heavier than 1 kg
7. repetitive movements of the hand and arm for at least 2 hours a day
8. Manual precision work
9. Frequent alternation between palmar flexion and dorsiflexion of the wrist joints
10. Frequent pronation and supination movements such as screwing, whereby the direction of the force exerted plays a role (supination is the risk factor)

– Other health factors

1. Age (especially over 45)
2. Smoking
3. Overweight

Diagnosis

1. Hypertonus of the extensors
2. Localised pressure pain
3. Tests and signs: Thomsen test (testet Handgelenkdorsalflexoren auf Exercise-induced pain), Mill test (testet Handgelenkdorsalflexoren auf Strain pain), Cozen test (testet Handgelenkdorsalflexoren auf Exercise-induced pain), Maudsley test (testet Extensor digitorum auf Exercise-induced pain), Bowden test, Chair test (testet Handgelenkdorsalflexoren auf Exercise-induced pain), definite yoga tennis elbow test cluster

Symptoms

1. Initially only pain on exertion, pain on stretching, later possibly also pain on movement or rest
2. pressive pain in the area of the affected epicondyli and in the area close to the tendon of the affected muscle
3. Painful hand pressure
4. Pain when gripping objects
5. Painful restriction of strength
6. Pain when straining or stretching the extensor apparatus of the wrist or fingers, especially with active supination, hyperextension of the fingers, dorsiflexion of the hand

Differential diagnosis

1. Radial tunnel syndrome (supinator syndrome)
2. Osteochondritis dissecans of the capitulum
3. radiocapitular arthritis
4. Varus-instability
5. posterolateral rotational instability

Therapy

1. Immobilisation (not the elbow!)
2. Strengthening training (HSR, heavy slow repetitions); in rehabilitative training (in contrast to sport and everyday life) up to NRS-3 or even NSR-5-equivalent pain may be felt if the pain subsides within 24 hours and does not increase over the exercise units
3. Injection of local anaesthetics if necessary
4. Local costisone infiltration
5. Analgesics, anti-inflammatory drugs if necessary
6. Stimulation current therapy
7. Homeopathy, Traumeel
8. Cooling in the acute stage
9. warming later
10. Stretching
11. progressive strengthening therapy with pain avoidance
12. Transverse friction
13. Epicondylitis brace, taping
14. Taping
15. Therapy duration approx. 4 months
16. Long-term therapy/prevention: Maintaining the stretching ability of the palmar dorsiflexors and finger extensors, strength training (preferably HSR, heavy slow repetitions)

Asana practice and movement therapy

With tennis elbow there are significantly fewer restrictions for the asanas than with golfer’s elbow. Above all, care must be taken to ensure that wide dorsiflexions of the wrist are not painful. This will mainly occur in combination with supination of the arm, less so in pronation. Typical postures in which the pain can occur are therefore

1. purvottanasana
2. Shoulder stand
3. setu bandha sarvangasana
4. urdhva dhanurasana with hands turned backwards

In some cases, the pain decreases or disappears when the antagonistic palmar flexors and finger flexors work more intensively. As a rule, the finger extensors will be the main pain triggers. This can be controlled by releasing the dorsal fist closure in the forearm stretch. If not only the stretching of the forearm muscles but also the epicondylitis pain disappears, the finger extensors are definitely involved in the pain. Once the fist has been released, the wrist can usually be flexed further dorsally. If not only stretching but also epicondylitis pain occurs again, then pure dorsiflexors of the wrist are also involved in the pain. In addition to stretching the dorsal flexors and finger extensors, these should also be strengthened, if possible again without triggering pain, i.e. with a sufficiently low weight or with a medium weight only up to the point where the pain is triggered. In both cases, a high number of repetitions is indicated. As with the golfer’s elbow, functional strengthening exercises with dumbbells are an excellent scalable exercise in terms of ROM and force application. In the case of forearm supination tennis elbow, i.e. when the supinator muscle is affected, strengthening this muscle, for example as described in Exercisingsupination and pronation of the arm, is the most important therapeutic pillar. If a wrist dorsiflexiontenniselbow is present, the dorsiflexion of the wrist should be practiced in particular using the palmar flexion and dorsiflexion of the wrist exercise, and the flexor carpi ulnaris should also be strengthened if necessary by performing its ulnar abductor function using the radial abduction and ulnar abduction exercise. It is therefore very helpful to first find out which type or mixed type of tennis elbow is present by testing for pain on extension and pain on exertion.

In deviation from the general rule of strictly avoiding the relevant pain, the procedure described there can be used for the exercises described, in which the development of the pain, which can be at NRS 6-8, 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 up to a maximum of NRS 2-3.

Asanas

Dorsal forearm stretch
Practicing supination and pronation of the arm
Practicing radial abduction and ulnar abduction