yogabook / pathologie / tennis elbow

Epicondylitis humeri lateralis/radialis / tennis elbow/ tennis arm

Definition of

painful insertional tendinopathy at the muscle origins of the wrist dorsiflexors and finger extensors on the lateral epicondyle of the humerus. 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, the condition is said to become chronic after 6 months. 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 to the point of muscle hard tension (like a permanent contracture) resulting in tendon and periosteum over-irritation and intratendinous necrosis. The most commonly affected muscles are extensor carpi radialis brevis and extensor communis, but possibly also supinator and other wrist dorsiflexors such as extensor carpi radialis longus, extensor digiti minimi and extensor carpi ulnaris.

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

1. Unterarm-Supinations-Tennisellbogen: betroffen ist der M. supinator
2. Handgelenk-Dorsalflexions-Tennisellbogen: betroffen sind Extensor carpi radialis brevis, Extensor carpi radialis longus oder Extensor carpi ulnaris
3. Fingerstreckungs-Tennisellbogen: betroffen sind Extensor communis oder Extensor digiti minimi

Natürlich können auch Mischtypen vorliegen.

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 arch makes metabolism and healing/repair after overuse more difficult,
which leads to hyperplasia of less vital cells starting from the uppermost layer of the tendocytes. The term tennis elbow is very plausible in view of the strain 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 golfer’s elbow, the counterpart of tennis elbow, occurs much less frequently in the palmar flexors as a result of playing with the forehand is simply due to the fact that the palmar flexors in humans are on average much stronger and more robust. 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. Severe pain, persistence of pain for more than 3 months and depression also worsen the prognosis. Pathophysiologically, the tendon does not heal after stress and angiofibroplastic hyperplasia occurs. There is also a risk of calcification.

In Germany, tennis elbow has an annual prevalence of 6% with an age peak between the ages of 36 and 58, of which 89% improve with conservative therapy. Surgical intervention is only performed in 4-11% of cases.

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

ICD M77.0

Cause

1. Overloading, e.g. through tennis, mechanical work (assembly line production), intensive playing of a musical instrument, housework, formerly also for typists
2. Fluoroquinolone antibiotics (have a tendotoxic effect)

Predisposing

– Behavior of the musculoskeletal system

1. various sports such as rowing, tennis, other racket sports
2. various musical instruments such as violin
3. intensive use of the computer mouse
4. screwing movements (e.g. tightening screws – loosening screws, on the other hand, could lead to a gulf 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 wrists
10. Frequent pronation and supination movements such as screwing, whereby the direction in which the force is 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. localized pressure pain
3. Tests and signs: Thomsen test (tests wrist dorsiflexors for pain on exertion), Mill test (tests wrist dorsiflexors for pain on extension), Cozen test (tests wrist dorsiflexors for pain on exertion), Maudsley test (tests extensor digitorum for pain on exertion), Bowden test, Chair test (tests wrist dorsiflexors for pain on exertion), definite yoga tennis elbow test cluster

Symptoms

1. Initially only pain on exertion, pain on stretching, later possibly also pain on movement or at rest
2. Pressure pain in the area of the affected epicondyli
3. painful handshake
4. Painful restriction of strength
5. 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

Therapy

1. Immobilization (not the elbow!)
2. Injection of local anesthetics if necessary
3. Local costisone infiltration
4. Analgesics, anti-inflammatory drugs if necessary
5. Stimulation current therapy
6. Homeopathy, Traumeel
7. In the acute stage Cooling
8. warm later
9. Stretching
10. Progressive strengthening therapy with pain prevention
11. Transverse friction
12. Epicondylitis brace, taping
13. Taping
14. Therapy duration approx. 4 months
15. Long-term therapy/prevention: Maintaining the extensibility of the palmar wrist dorsiflexors and finger extensors

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