Tennis Elbow (Epicondylitis)

What is commonly known as a tennis elbow or lateral epicondylitis is actually only in exceptional cases the result of playing tennis. Terms that are more fitting would be “mouse elbow” or “handyman” elbow. Repetitious movements, such as working at the computer, especially when using the mouse, or overexertion due to excessive work with a screwdriver or hammer or even wringing laundry, can cause the annoying pain on the outer part of the elbow significantly more frequent than playing tennis does.

 

What is a tennis elbow?

The pain resulting from a so-called tennis elbow is mostly caused by overexertion and overloading of the tendon attachment. Either the tendon is acutely “overloaded” because manual work was performed with movements the patient was unaccustomed to or a chronically overexertion exists because the resting phase between straining repetitive movements was too short - it is the tendon on the outer part of the elbow that is painful. The corresponding muscles are located on the forearm and are responsible for the extension of the wrist. Accordingly, overexertion of the hand and not the elbow are the cause for tennis elbow!
When speaking about a tennis elbow, the patient mainly complaints about pain in the elbow when using the hand or the forearm muscles. Pain is felt most often during routine movements like pouring coffee or reaching for something. However, problems in the cervical vertebra column, such as chronic tension, may at times also be responsible for the actual elbow condition.

Only an accurate diagnosis can warrant a safe and successful treatment of a tennis elbow!

Prior to considering treatment of the elbow, a specialist should be consulted to ensure that the symptoms do indeed indicate a tennis elbow condition, or whether there are other causes for the pain. For example, pain can be caused by problems with the cervical vertebra column, a nerve inflammation, changes in the muscle structure, or even osteoarthritis of the elbow joint.
A comprehensive medical history reflecting when and how the pain has first occurred or when the pain seems to be more severe, as well as a thorough medical examination is the basis for a successful therapy. Supplementary, laboratory tests such as X-rays, ultra sound, and magnetic resonance imaging (MRI) of the cervical spine, the muscles, and specific nerves can be helpful in determining the cause and development of the condition.

What are the treatment options for a tenniselbow?

As with all treatments of sports injuries, the general principal should be “the least stressful treatment with the goal to bring about a lasting cure!” Especially in the case of a tennis elbow, the patient must understand the treatment concept since he or she must actively participate in the therapy.

Important measures

Rigorous treatment of the condition by the affected person him/herself! To successfully treat a so-called tennis elbow, it is essential that the arm will be relieved of any strain right at the place where the tendons are attached. The chronically increased tension must be released. For the patient relieving the tendon attachment means specifically:

• activities that cause pain, must be avoided
• the forearm muscles must be stretched regularly and intensively.

Through regular stretching exercises (3 to 4 times daily, repeating each 3 to 4 times and holding the forearm in the stretched position for about 20 seconds), the excessive tension of the muscles are normalized (s. image).
Another prerequisite for the healing of a tendon irritation is an improved blood circulation in the arm promoting self-healing of the tissue. Recommended are ice wraps 1 to 2 times daily. The area affected by the pain should additionally be rubbed down with ice for about 10 minutes. (A practical hint: make a popsicle/ice-lolly by freezing water in a yoghurt cup or other small plastic container inserting a wooden or plastic stick as a handle). The rubbing with ice increases the blood circulation to a maximum, which is comparable what you feel in your hands after a snowball fight.

Physiotherapy

Targeted physiotherapeutic measures are often beneficial if started at the early stage of the disease since they can avoid the condition to become chronic. With a special form of massage, the blood circulation deep in the tissues can thus be improved. Although, the so-called transverse friction is not comfortable for the patient, it is very effective. Ultra sound or electrotherapy work similarly. Physical exercises and manual therapy directly at the arm - at the cervical spine - regulate the tension in the muscles. Physiotherapeutic sessions of about 30 to 60 minutes should take place two to three times weekly.

Braces

The so-called epicondylitis braces or bandages cause pressure on the muscles helping to regulate the disturbed muscle tension and to create a slightly different tension of the painful tendon. An epicondylitis brace should be worn for several hours a day especially when the arm is being stressed. Experiences with bandages and braces vary considerably. Many patients respond well to such a bandage, while others will not notice any improvement.

Medicinal therapy

Treatments with drugs include ointments, tablets, or injections. Ointments are generally well tolerated. In case of a tendon irritation, ointments usually have only a limited effective. The use of anti-inflammatory tablets (diclofenac, ibuprofen, etc.) is only in exceptional cases recommended because side effects often outweigh the benefits.
In more progressive, more severe lateral epicondylitis (tennis elbow), the treatment with targeted injections into the irritated tendon with an anti-inflammatory drug is recommended.
Particularly effective is a low-dose cortisone preparation with a depot effect. Injections should, however, not be administered more than two or three times at intervals of about four to six weeks since otherwise damage to the tendon may occur. With less severe and chronic conditions, lasting treatment results are more likely to be expected with homeopathic-inflammatory drugs or drugs stimulating the metabolism. These medications must usually be injected at the tendon insertion six to eight times at intervals of one week. For optimal results, the treatment can be combined with a neural therapy.

Autohemotherapy (ACP / PRP)

In recent years, the use of autologous blood for the treatment of tennis elbow has become a very successful method. In this process, anti-inflammatory growth factors and analgesic messengers from the blood of patients are processed in a centrifuge and isolated. They can then be administered in a concentrated form by injection directly to the degenerative changed in tendon tissue.

Botox therapy

Recent studies suggest that the local muscle treatment with Botox can be successful. With the botulinum toxin the nerve conduction is reduced and thus relaxes the muscles permanently. Currently, this method is an experimental treatment form that needs to be further investigated in trials before a general recommendation can be made.

Extracorporeal shockwave therapy

Pneumatically generated acoustic waves are targeted onto the tendon insertion. A course of Radial Shockwave Therapy (RSWT) typically consists of four to five treatments sessions administered over a three to four week period after the initial diagnosis. These ultrasound waves aim at reducing the pain and at healing the inflamed tendon.

Acupuncture

Acupuncture is an alternative treatment that produces astonishing results when administered by an experienced physician. It leads partly to amazing improvements of the tennis elbow condition. With acupuncture, on the one hand, the tension of the muscles are directly affected, on the other hand, the pain cycle resulting from the tension, is interrupted without any side effects. Treatment consists usually of 10 to 20 sessions twice a week.

Surgical Treatment

Surgical treatment of a tennis elbow should be an option only after conservative treatments have failed. It is recommended if a longer-term intensive conservative treatment in combination with measures taken by the patient, physical therapy, and medical treatment does not lead to lasting improvement of symptoms. During surgery, through a small, about 3 cm long incision, the tendon is detached from its insertion and sutured. In addition, sensitive nerve endings that are responsible for pain transmission are isolated. The procedure can be performed on an outpatient basis. The first two weeks after surgery, the arm should be strictly immobilized. After a recovery period of about six weeks, gentle mobilization/strain of the elbow can be restarted. Full load capacity is expected after 10 to 12 weeks.

Jan Vonhoegen, M.D., (USA) presents a new treatment method in the therapy of the chronic tenniselbow:

Recent studies have shown that in particular changes in the tendon of the short extensor wrist (extensor carpi radialis brevis) are responsible for a chronic tennis elbow. With minimally invasive surgery - arthroscopy, a method that is used very successfully in other joint diseases already for many years - shoulder specialists can remove the diseased tissue from the tendon. In an arthroscopy, an arthroscope (a small camera instrument about the size of a pencil) and other small surgical instruments are inserted into the area of the outer elbow via two few millimeter-long incisions. The tendon damage is thus visible to the surgeon in detail and can easily be treated.
Multiple patient studies from the United States showed that the treatment of tennis elbow by means of arthroscopy are up to 92% very good short-term and long-term constitution a very low risk of complications.

The arthroscopic procedure is much gentler, less risky, and significantly less painful than traditional surgical procedures. Specifically, this means that the patient can expect a quicker recovery period of 2 to 4 weeks without an immobilization of the elbow, while an open surgery requires a healing and post-treatment period of about 3 months.

Your specialist in the treatment of tennis elbow

Only an individually conceptualized treatment approach based on comprehensive preliminary examinations ensures optimal healing of a tennis elbow. The team at the KILINIK am RING has extensive experience in the diagnosis and treatment of elbow joint injuries, conditions, and disorders. Jan Vonhoegen, M.D. (USA) is specialized in the arthroscopic treatment of the tennis elbow.