Tennis elbow is a painful inflammation of the tendon attachment at the elbow. Especially tennis elbow, which lasts several months, is difficult to treat and requires sufficient experience.
What is tennis elbow?
Tennis elbow – also known as epicondylitis humeri lateralisradialis – is a painful irritation of tendons that attach to the outside of the elbow. The main trigger is considered to be a permanent overstrain of the forearm muscles caused by monotonous movements without adequate relief. Via the respective tendons, the muscles of the forearm attach to the elbow or upper arm, which are mainly responsible for stretching the wrist and fingers. Most tennis elbows heal with proper therapy, but only rarely does the limitation become chronic. Important facts about the causes, treatment options and exercises as well as the course and prognosis of tennis elbow are discussed in more detail below.
How is tennis elbow treated?
The treatment of tennis elbow can be divided into a conservative and an operative treatment. As a rule, the conservative therapy is started with the conservative therapy, which includes not only protection and, if necessary, immobilization of the elbow joint, but also regular cooling. Painkillers or cortisone containing ointments (bandages), bandages or cuffs, physiotherapeutic treatment (strengthening training, stretching exercises, massages, etc.)
and acupuncture are also part of the conservative treatment measures. Local injections can also be made into the area of the elbow, which contain a mixture of local anesthetic and cortisone. Painkillers can also be taken in tablet form, with preference being given to non-steroidal anti-inflammatory drugs (NSAIDs, e.g. diclofenac, ibuprofen), which have an anti-inflammatory effect in addition to their analgesic properties.
If the conservative therapy is unsuccessful, the step can be taken to surgical therapy, whereby there are various procedures to relieve tennis elbow. Another therapy attempt for chronic complaints is the injection of botulinum toxin (also known as Botox) into the muscle to “paralyze” it for 2-3 months so that it can recover. One possibility of conservative therapy of tennis elbow is the application and wearing of a tennis elbow bandage or tennis elbow brace.
Therapy with a bandage or brace plays a very important role in the acute phase, while both aids become less efficient in the chronic phase. In the case of still existing tennis elbow together with cooling, protection, painkillers, physiotherapy and stretching exercises, this can help to relieve the affected muscles and to heal, but it can also prevent a recurrence after successful therapy and still existing, heavy strain on the forearm muscles. A bandage/clip does not restrict the freedom of movement as consistently as a plaster cast, for example, but rather guarantees an unrestricted range of motion.
The purpose of such a bandage/clip is to exert targeted pressure, concentrated on the point of attachment of the tendons at the elbow, which relieves the muscles of the forearm and relieves pain. Such cuffs can be purchased over-the-counter in various sports stores and medical supply stores, but advice should be sought from the treating physician as to which type of bandage brace is most suitable. Care should also be taken to ensure the correct size and fit, as otherwise even more unpleasant complaints can be caused by a too tight, constricting bandage.
Your doctor can easily tell you whether you benefit more from a bandage or brace. The wearing time of the bandage, brace or cuff depends on various factors. As a rule, the aids should only be worn during the load (during sports, at the PC) to relieve the tendon.
Where the elbow is not exposed to any strain, no bandages or similar should be worn, as this interferes with the healing process through compression. Taping in the context of tennis elbow can also be considered a supportive therapy measure and can support conservative treatment, i.e. non-surgical treatment. Taping can be done with elastic tapes (e.g.
kinesio tapes) as well as with inelastic tapes (e.g. Leukoplast). Elastic kinesio tapes are used to support healing. Non-elastic tapes help athletes to be less painful during sports.The type of tape to be used depends entirely on what exactly is to be achieved with the tape: inelastic tapes have a rather “splinting” function – similar to bandages or fixed traction bandages – they restrict the range of movement in the elbow somewhat and support the immobilization.
Elastic tapes (kinesio-tapes), on the other hand, restrict movement less or not at all, at most support the movements and promote or activate the blood circulation, the misused musculature and the lymph drainage, so that pain relief, swelling and inflammation control can be achieved. The tapes should always be applied or glued by an expert, since incorrectly or too tightly glued tapes can also lead to other complaints, such as circulatory problems. Stretching exercises can be performed during acute tennis elbow and help to heal, but they can also be used regularly in everyday life after tennis elbow has been overcome to prevent recurrence.
For example, the following exercise can be performed 2-3 times a day: The arm is stretched straight forward at a 90° angle away from the body, the elbow should not be bent. With the palm of the hand pointing upwards, the hand in the wrist is now bent downwards and held in this position for about 30 seconds with the help of the other hand. It often happens that pain occurs during stretching exercises and exercises with the Theraband.
At the beginning of the therapy, an unpleasant feeling on the outer elbow can initiate the end of the respective stretching exercise. However, there should never be pain during stretching or stretching to slightly above the pain threshold. In each case, when the stretching exercises can be performed without pain, the repetition of the exercises during the day can be increased.
However, this should be done in consultation with the treating physician or the supervising physiotherapist. To support the healing process, various exercises can be performed, which are often used in the context of physiotherapy. These include strengthening exercises for the forearm and hand muscles as well as stretching exercises to prevent incorrect strain and muscle shortening.
Stretching exercises should already be carried out to accompany pain therapy, but strengthening exercises should only be carried out in the pain-free stage or after complete healing to prevent a recurrence of tennis elbow. Exercises with the Theraband are a popular way to treat the symptoms of tennis elbow. By using the Theraband, the tendon is stretched and strained.
This can, if used correctly and regularly, bring the disease to healing and significantly alleviate the symptoms. The flexible exercise stick of Thera Band is grasped with both hands during the exercises, and then turned forward with the hand of the affected side while the other hand holds the stick. Then the hand is slowly moved back to its original position.
Important: The exercises must not cause any pain. In the treatment, exercises are measures that support the healing process and are rather harmful in the acute phase of tennis elbow! Another therapy option is the administration of an injection into the area of the inflamed elbow joint, whereby this injection consists of a mixture of local anesthetic and cortisone.
The cortisone has an anti-inflammatory effect, the anesthetic quickly and temporarily relieves the pain. A cortisone injection is an efficient way to end the disease, especially in the initial phase of tennis elbow. In phases of chronic tennis elbow an isolated cortisone injection cannot help anymore.
The side effects of a locally administered cortisone injection are usually manageable and are often overestimated by those affected. As a practitioner of thousands of tennis elbow injuries, I cannot confirm a torn tendon – as often described elsewhere – when used correctly. Nevertheless, even the use of the cortisone injection is not a procedure of first choice.
Shockwave therapy, like radiation, is a non-invasive therapy option for tennis elbow, i.e. a therapy that does not penetrate, i.e. does not open up the body surface, as would be the case with surgery. This procedure is used by various orthopaedic surgeons for the treatment of severe, protracted, chronic tendon insertion inflammation.Strictly speaking, shock waves are electromagnetically generated acoustic waves that are directed to the affected part of the body and exert pressure there through the impulse and the energy transfer.
This pressure is intended to irritate the respective tissue, stimulate the blood circulation and cell metabolism and promote complex healing processes. The pain symptoms can also be reduced by the application of shock waves, but the exact mechanism of action in all its details has not yet been deciphered. Shockwave therapy is an efficient reserve procedure when other therapy methods have failed or the symptoms persist for more than 6 months.
As with all therapeutic procedures, the success of shock wave therapy depends particularly on the experience of the user. As a rule, surgery for tennis elbow is only considered if the success of an exhausted conservative therapy fails and there is no improvement of the symptoms after a good 6 months of conservative therapy. The operation can be performed on an outpatient or inpatient basis, whereby the former is the actual standard procedure.
In addition, the operation can be performed under local anesthesia, which means that only the arm is anesthetized, but general anesthesia can also be used if desired or under certain circumstances. There are three different surgical options: The operation – except for the minimally invasive one, which can be performed within 5-10 minutes – usually takes between 30-45 minutes. After successful surgery, the elbow is immobilized in an upper arm cast for 5-14 days as part of the post-operative treatment.
The minimally invasive method usually does not require immobilization.
- Hohmann’s operation, in which the affected tendon is removed from the elbow joint
- The operation according to Wilhelm, in which the nerves responsible for the sensitive care of the elbow are cut and sclerosed and
- The minimally invasive surgery, in which one of the two surgical procedures is performed through a very small skin incision of only 1 cm in size.
During an operation on tennis elbow, the affected tendon and muscle attachments are usually separated from the bony protrusion. After immobilization for 1-2 weeks, the arm should be moved through again.
Careful stretching exercises are also part of the physiotherapeutic follow-up treatment after an operation of a tennis elbow. These can prevent the tendon from re-growing at the elbow and thus a recurrence of the tennis elbow. The intensity of the exercises can be determined together with the treating physiotherapists and can also be done independently at home.
Irradiation in the context of tennis elbow is the so-called X-ray stimulation radiation. As the name suggests, it involves the use of X-rays that are directed specifically at the area of the elbow and is a long-established procedure for treating inflammation of tendon attachments. Like surgery, the irradiation of a tennis elbow is only a reserve therapy, which can be applied after at least 6 months of unsuccessful conservative therapy.
Usually 6 applications are carried out, 2 of them in one week. Often the symptoms initially worsen during the treatment, but this is not serious, but rather represents a good response to the treatment. The final result, i.e. the alleviation of the symptoms, often occurs 3-4 months after the last irradiation.
Physiotherapy has a very high priority in the treatment of tennis elbow, both for regeneration and for the prevention of tennis elbow recurrence. Physiotherapy includes targeted strengthening exercises to strengthen the forearm muscles, stretching exercises and massages. In the very acute stage of the disease, i.e. when the inflammation is at its most pronounced, physiotherapy should not be performed, especially no stretching exercises and massage applications, as these could sometimes promote and aggravate the inflammation.
In addition, physiotherapy is used to determine the triggering circumstances, i.e. the patient is also examined for incorrect posture and posture corrections (e.g. in the spine or at the workplace) are carried out. Further physiotherapeutic measures can also be:.
- The electrotherapy
- The ultrasound therapy and the equipment of
- Tape bandages (Kinesiotape)
Homeopathy can also be used to help with tennis elbow. Especially the following homeopathics are used:
- Apis (honey bee)
- Arnica (mountain lodging)
- Calcium phosphoricum (calcium hydrogen phosphate)
- Bryonia (red berry fenugreek)
- Potassium iodate (potassium iodide)
In addition, an osteopath can also be consulted, who will manually diagnose the functional disorders causing the problem and will not only focus on the overstrained forearm muscles, but will also pay holistic attention to the cervical/chest spine, shoulder and ribs. However, osteopathy plays only a minor role in the treatment of tennis elbow.
The use of ointments can be part of the therapy and can certainly be tried. As a rule, the ointments to be applied and rubbed in contain certain active ingredients, which are mainly used to combat the pain symptoms or even have an anti-inflammatory effect. Well-known are ointments such as Voltaren Emulgel®, which contain the active ingredient Diclofenac, which is a painkiller from the group of non-steroidal anti-inflammatory drugs (NSAIDs).
In addition, ointments containing cortisone can also be used, which also have an anti-inflammatory effect. Because tennis elbow is an inflammatory process, the application of cold is the remedy of choice in this case. Cold relieves the inflammatory symptoms such as pain, swelling, redness and overheating.
If heat is applied to an inflammation, the pain and inflammation may even worsen, which is caused by the increased blood flow (heat causes the blood vessels to dilate, allowing more blood to flow in). Cooling compresses or ice can be used, but too long or intensive application should be avoided to prevent skin damage. With regard to a consistent immobilization of the elbow joint for the therapy of tennis elbow, an upper arm cast can be used, but immobilization by independent protection, bandages, tapes, etc.
should be preferred. It is therefore neither the method of choice nor a permanent therapy option, but the cast should only immobilize for a short time, if at all. Immobilization with an upper arm cast, which includes the elbow, causes the muscles to regress very quickly. If the subsequent training for reconstruction is incorrectly carried out, a new incorrect/overload can easily occur, which can result in renewed tennis elbow.
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