Shock wave therapy for a golfer’s elbow

Shockwave therapy is used for the golfer’s elbow when the usual conservative treatment options for the golfer’s elbow have failed, but one does not yet want to go as far as to perform surgery. Meanwhile this therapy form is mentioned in the guidelines of the therapy. However, there are still many who are sceptical about this type of treatment.

Unfortunately, the statutory health insurance companies steadfastly refuse to cover this effective therapy. How exactly shock wave therapy helps the golfer’s elbow is not yet understood in the smallest detail. However, it is suspected that the pathologically altered tissue structures at the affected muscle or tendon attachments are crushed into tiny particles by the ultrasound impulses used, which trigger regenerative processes at the tendon.

In addition, the “shock” caused by the shock wave initiates repair mechanisms and stimulates blood circulation, which also helps to accelerate the healing of the tissue. As a rule, extracorporeal shock wave therapy (ESWT) is performed on an outpatient basis for a golfer’s elbow patient without the need for anesthesia or local anesthesia. It works by first covering the diseased area of the elbow with a contact gel.The shock wave head of the device, which is similar to that of a kidney stone crusher, is then directed at the painful area and shock waves (ultrasound pressure waves) are transmitted into the affected area.

With the golfer’s elbow, low-energy shock waves can normally be used for this purpose, since the tendon attachments are located relatively directly under the skin. Many patients experience the shock wave therapy as a small blow and therefore find the therapy unpleasant. However, if it is carried out correctly, the treatment is otherwise rarely associated with complications.

Various smaller nerves and blood vessels run along the inner elbow, which are sometimes irritated by the shock waves. This can lead to bruising or pain in the area of the treated area. If the treatment is not carried out correctly, in the worst case, damage to the ulnar nerve (nervus ulnaris) may occur, which can cause problems especially when spreading and closing the fingers.

If the already existing pain is made worse by the treatment and this does not subside even during the second or third session, the shock wave therapy should be discontinued and switched to one of the other therapy options. The success rate of about 80% is quite high. However, one must also bear in mind that the success depends on a number of external factors, especially the time at which the therapy is started.

In an early stage, shock wave therapy helps more reliably than in the chronic stage. Nevertheless, it is a very effective method, especially in the case of chronic golfer’s elbow, which is becoming increasingly popular due to its low side effects and the good prospects of complete healing. In some cases it may be useful to use other methods in parallel to extracorporeal shock wave therapy to optimize the therapy, for example physiotherapy or pain-relieving, anti-rheumatic drugs.

If after six months of treatment there is no improvement of the symptoms or even a worsening, surgical therapy should be considered together with the treating physician. Unless there are circumstances that speak against it, such as a lack of care at home after the operation or complications associated with anesthesia in previous operations, it is usually possible to perform the operation of the golf elbow on an outpatient basis. Furthermore, the operation is often minimally invasive, which means that the surgeon inserts his devices through small skin incisions and a complete opening of the joint is not necessary.

However, it should be noted that the ulnar nerve runs close to the affected joint and special care is required during surgery. Some surgeons therefore still prefer conventional surgery with opening of the joint. Which procedure is used in each individual case must be decided with the treating physician.

The anaesthesia can be either a regional anaesthesia into a vein, a plexus anaesthesia, i.e. anaesthesia of all nerves in the armpit and thus of the entire arm, or in special cases a general anaesthesia. There are two standard procedures for performing the operation. In the Hohmann surgical technique, the origin of the muscles that start at the elbow and cause pain is cut through.

To do this, a small incision is first made at the elbow with a scalpel and the underlying muscles and their attachments are exposed. Since the skin is very elastic, the incision does not need to be large. The surgeon can simply push the skin a little to the side to see all the important muscles.

This allows the surgeon to see the muscle attachments that are under tension and thus responsible for the pain in the elbow. Now these tense fibre strands are cut through, thus relieving the arm. Those muscle attachments that are loose and relaxed remain untouched and preserved, as they have nothing to do with the origin of the pain.

Once all the necessary attachments have been severed, the surgeon checks the free movement of the arm in the operating room and under anesthesia. In addition, the surgeon tests whether a firm handshake by a third person reveals a depression near the elbow. This is normally the case.

If the surgeon is satisfied with these two tests, the wound is closed again.In the second standard technique according to Wilhelm, the smallest nerves responsible for supplying the elbow and thus for transmitting the pain to the golfer’s elbow are severed and sclerosed. This process is also called denervation. Mostly a combination of both techniques is used.

After the operation on the golfer’s elbow, the arm is immobilized with an upper arm cast for about two weeks. After the plaster splint has been removed and the stitches removed, movement exercises should be performed if there is no pain. In some cases, physiotherapy is also useful.

The costs for such an operation are currently not covered by many statutory health insurance companies, so you should inquire with the respective health insurance company in good time. In addition to medical, conservative and surgical treatments, the use of homeopathic remedies is another option. At the beginning of a homeopathic treatment there is usually a detailed anamnesis interview.

The focus is not only on the actual complaints, the golfer’s elbow, but also on the whole person and his current condition. In this way the homoeopath tries to get an impression of the overall situation and to distinguish symptoms caused by the golfer’s elbow from symptoms of other origins. Based on this conversation, the homeopath can then decide which remedy should be used in the case of the individual patient.

It is therefore difficult to give a general indication of useful substances. The following remedies are used in the homeopathic therapy of the golfer’s elbow, depending on the patient’s symptoms, i.e. whether the pain improves or worsens with warmth, for example

Bryonia, the fence turnip, is used in homeopathy when patients have problems with movement and feel rather stabbing pain, which gets better under pressure and cold.
Arnica and ruta are also used for treatment after overuse. Both substances can be applied externally.
Also worth mentioning are rhus toxicodendron, which improves the symptoms of movement and heat and at the same time worsens when it is wet, rhododendron, which is felt to be unpleasant to touch, and acidum hydrofluoricum, the hydrofluoric acid.

From the field of traditional Chinese medicine, many doctors and therapists use acupuncture to treat the golfer’s arm.

A naturopathic approach is the leech therapy. Here, the affected elbow is covered with leeches, which remain there for about 30-60 minutes until they fall off on their own. Until now it is not clear how the effect of the leech therapy is achieved.

The predominant theory is that the saliva of the leeches contains substances that support the relief of the inflammation. Hedgehog therapy can not only be used to treat the golfer’s arm, but patients with rheumatic diseases or arthrosis are also successfully treated with leeches. Sports bandages are able to immobilize the joint for some time and promise relief.

Special elbow bandages ensure a gentle position, but at the same time allow partial use of the joint. Kinesiotaping involves applying an elastic adhesive bandage directly to the skin. This has a regulating effect on the muscular balance in the elbow joint.

Kinesiotapes are used both therapeutically and preventively. The effect of Kinesiotapes is indirect through the stimulation of skin receptors on the muscles. Depending on the desired effect, different application techniques are available.

The application technique is determined in consultation with a physiotherapist and a doctor. However, this effect has not been scientifically proven. Before applying the tapes, the skin must be cleaned so that it is free of oils, creams and hair.

This increases the durability of the tapes on the skin. The tape should be left on for about 1 week, whereby the main effect is expected in the first 3-5 days after application. Bathing, swimming and sports are also possible after the application.

If necessary, itching may be felt under the tape, if this occurs, it should be removed. Creams or gels with anti-inflammatory agents such as Diclofenac are suitable for superficial application.A stronger effect is achieved if pain and anti-inflammatory drugs in the form of tablets are taken for some time. These are for example Ibuprofen or Diclofenac.

These active ingredients can cause irritation of the stomach lining, which is why additional medication, e.g. pantoprazole, may have to be taken to protect the stomach.

Alternative medicine / naturopathy
Bandages
TAPE treatment
Drugs

There is also the possibility of injecting painkillers at the affected elbow to relieve the pain. Cortisone is also suitable for injection and inhibits inflammation in the golfer’s arm.

However, caution is advised, as the inflamed area in the golfer’s arm is very close to the ulnar nerve. During the injection, the doctor injects the selected substance into the irritated tissue, but he must not hit the nerve, as this causes a sudden stabbing pain on the one hand, and on the other hand the nerve may be damaged by cortisone. If the inflammation in the affected arm is acute and very painful, physiotherapeutic measures should be avoided at first.

It is advisable to wait for initial pain relief and containment of the inflammation while taking it easy and using other treatment concepts. If only mild symptoms are still present, physiotherapy can be started. It has been shown that especially stretching the surrounding muscles is very promising and often exceeds the benefit of other therapies.

Suitable stretching exercises are presented under the heading Exercises. The decision to have surgery on the golfer’s arm should be carefully considered. It is recommended that conservative therapies are initially performed for six to twelve months, as surgery cannot guarantee a cure.

As a rule, the operation of the golfer’s arm can be performed on an outpatient basis, i.e. there is no need for hospitalization. The operation is usually not performed under general anesthesia, but with plexus anesthesia. During this procedure, local anesthetics are used to numb the nerves of the arm so that the patient does not feel any pain.

Most surgeons operate on the golfer’s arm by making a small incision over the affected tendon attachment, then severing it and removing any calcifications so that the tissue is not further irritated. This technique, which is called Hohmann’s operation, can be combined with the obliteration of small nerve endings in the elbow joint, so that no more pain can be transmitted. This procedure is called surgery according to Wilhelm.

Compared to tennis elbow, there is a higher risk of damage to the ulnar nerve when operating on golfer’s elbow, since it is located in the immediate vicinity of the surgical field. In order to minimize this risk, the surgeon must know exactly where the nerve is located. Therefore, after the skin incision, the surgeon is first visited before the actual operation begins.

Injections
Physiotherapy
Operational approaches

Stretching exercises are a good way of preventing pain, as is the case with the golfer’s elbow, or of improving already existing pain. These relieve the tendon attachments and thus prevent a state of tension of the muscle attachments that leads to pain. It should be noted, however, that the exercises should ideally be performed in consultation with a doctor.

Furthermore, it is advisable to consult a doctor if the pain does not improve or even gets worse. The tendons of the wrist flexors, i.e. the tendons that are attached to the inside of the elbow, are stretched, for example, by stretching the arm where the golfer’s elbow has occurred horizontally forward with the palm of the hand facing upwards. Then the hand is bent downwards in the wrist, i.e. towards the ground.

With the other hand, grasp the fingers and help to move down until you feel a stretching at the inner elbow. The same effect can be achieved by placing the flat hand on a table top with the fingers pointing towards your body. In both exercises it is especially important that the affected arm remains stretched the whole time.