Golfers Elbow

The so-called golfer's elbow is medically referred to as epicondylitis humeri ulnaris (epicondylitis humeri medialis). Patients suffering from a golfer's elbow have pain on the inside of the elbow, in the area of ​​the bone protrusion where the tendons attach. Accordingly, a golfer's elbow is a so-called tendonitis (= endosis of the neck) of the forearm flexor muscles. The cause of the chronic inflammation at the medial humeric epicondyle is unclear, but it is assumed that overuse at work or sports (e.g. golf) have a mechanical effect. This also explains the origin of the term "golfer's elbow". Other tendons can also be affected by pain in the elbow.

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Golfer's Elbow 2020-03-13 Golfers Elbow
More About Golfers Elbow

Quite often, patients complain of the elbow pain radiating down to the forearm and / or upper arm, so that the entire arm can sometimes hurt. As a rule, there is local stabbing pressure pain at the bone attachment of the affected muscles, as well as inflammatory pain on the inside of the elbow (inflammation of the elbow), which is caused by fist closure and flexion, especially against resistance.

Golfer's Elbow Symptoms

If the patient has a golfer's elbow, he feels pressure pain on the inside of the elbow, where swelling may also occur.

Pain-wrenching or the flexing of the hand and forearm are especially aggravating against resistance, so that the patient is increasingly restricted in everyday life.

The pain often radiates into the upper arm as well as the forearm and the hand, so that the patient describes a pain in the whole arm and there is a decrease in strength of the hand and finger muscles, which is why the patient can no longer grasp properly.

The symptoms of the golfer's elbow are triggered by pain-releasing substances, for example the so-called substance P or prostaglandin E2, which are released as part of changes in the muscle attachments as a result of incorrect or excessive strain and irritate nerves, which then transmit this signal as a pain stimulus to the brain.

The typical complaints of the golfer's elbow can be described as stinging pain on the inside of the elbow, which often radiates down to the flexor side of the forearm. The symptoms often appear with increasing intensity when the muscles are stressed, for example when a fist is formed or when gripping an object when the arm is stretched. Flexion of the wrist and fingers is also affected, especially if the movement is against resistance.

The stress-related complaints often lead to a massive restriction in everyday life, since even simple tasks such as writing or lifting objects can become a problem due to pain. Many patients also report pressure pain on the inside of the elbow. This also extends along the flexor muscles on the forearm. In addition, not only is active movement causing discomfort, but also maximum passive stretching. If there is further stress or therapy is absent, the pain can also occur at rest.

After a golfer's elbow has been diagnosed, the painful arm is often immobilized, for example using a splint, for up to two weeks. After this, the immobilization should be released again, otherwise the muscles can be shortened and, as a result, the joint can be stiffened.

Treatment may be lengthy, but is necessary to prevent chronic development. If the golfer's elbow has been treated by surgery, the arm is immobilized with a splint for 10 to 14 days, depending on the healing. The movement is then optimized again using various physiotherapy exercises. The duration varies individually and depends, among other things, on the patient's cooperation, but also on how the patient's body copes with the stress. Inability to work depends on the professional activity and is usually between two and eight weeks.

Golfer's Elbow Causes

The term "golfer's elbow" does not mean that only golfers or athletes suffer from this disease. In fact, the "golfer's elbow" occurs only relatively rarely in athletes, mostly as a result of incorrectly learned technique.

As the golfer's elbow is caused by chronic mechanical overuse, craftsmen, mechanics, road and construction workers or secretaries are particularly affected.

In the course of the disease, painful wear and tear in the attachment area of ​​the flexor muscles of the wrist occurs. The golfer's elbow often also occurs in older patients. In some cases, studies have shown pronounced degenerative (arthrotic) changes in the elbow joint.

The muscles of the forearm are hung on the inside at the end of the humerus. With it, people can bend both the elbow, the wrist and the fingers.

The muscle tendons of this muscle group are therefore stressed with many movements.

The causes of a golfer's elbow mostly lie in an overloading or incorrect loading of the arm concerned.

The reasons for this can be varied, a golfer's elbow not only occurs after playing golf, but can also be triggered by other activities.

Typical triggers are heavy loads on only one arm, for example when climbing, especially when the movements are not technically clean.

In everyday life, a golfer's elbow can also occur, which is often triggered by hours of operating a computer mouse.

Why these strains lead to an inflammatory process in the muscles is not fully understood, but the mechanical irritation of the tissue plays a major role.

Diagnosis of a golfer's elbow

The diagnosis can usually be made on the basis of a medical history and a simple physical examination.

The doctor will trigger typical pain points through pressure.

It is important to ensure that there are no bones or elbow injuries that cause similar symptoms.

Additional tests are also carried out, such as the provocation test:

When the elbow joint is extended, the wrist is extended and the arm is supported on a table with the ball of the hand. The pain on the inner elbow increases with the golfer's elbow.

In this test, the flexion muscles on the forearm are used to the maximum. An increased pull is exerted on the tendons attached to the inner elbow. The diseased tendons react to this with increased pain.

To exclude other diseases, an X-ray can be taken, on which one can see whether the pain is caused by old fractures, for example.

The occupational groups at risk include those who have to use the forearm flexors intensively. These are in particular craftsmen, mechanics or construction workers.

Due to the severe pain of the golfer's elbow, which occurs more and more frequently during everyday activities and is sometimes so severe that even lifting light objects becomes a pain, the patient visits a doctor. Patients often complain of the pain radiating down to the forearm muscles.

During the clinical examination of the golfer's elbow, severe pressure and touch pain on the affected tendon attachments must be triggered. Due to pain, there is a restriction of movement in the elbow joint, but this is relatively rarely triggered by degenerative / wear-related changes.

As part of the medical examination, the doctor performs a resistance test on the golfer's elbow. The patient has to make a fist and push up or down against force. If there is a disease in the tennis elbow or golfer's elbow, this test causes pain in the elbow joint. Often the entire forearm muscles are very tight and under certain circumstances there may also be slight emotional disturbances, which can be felt, for example, by a tingling sensation. They are usually not caused by cervical syndrome (cervical spine syndrome) or local nerve damage.

A strong, stabbing pain occurs when pressure is exerted on the origin zones of the finger and hand reflectors. Due to the patient's pain, there is always a restricted movement of the elbow joint. However, this is only rarely due to degenerative changes and is more pain-related.

During an ultrasound examination, the doctor can detect a swelling in the area of ​​the tendon insertions, while abnormalities can only be seen very rarely and usually in more advanced stages during x-ray examinations of the elbow joint. In cases where the golfer's elbow has already reached a chronic stage, calcification foci in the area of ​​the tendon attachment or small periosteal irregularities (= periosteal skin irregularities) as well as bone extractions may be recognizable on the X-ray image.

The doctor must distinguish from epicondylitis humeri ulnaris (= golfer's elbow), for example epicondylitis humeri radialis (= tennis elbow).

In order to be able to differentiate this safely from one another, the tests listed below help the doctor.

Physical treatment of Golfer's elbow

As with other inflammations in the body, it is helpful to cool the golfer's elbow. This stops inflammatory processes and relieves the pain. It is advantageous that the cooling of the painful areas can also be carried out by patients themselves. In addition, many physiotherapists use electrostimulation to treat golf gams.

The technique used is called TENS, which stands for "transcutaneous electrical nerve stimulation". Here, electrical impulses are delivered to the skin via electrodes. This procedure is intended to reach the nerve fibers that transmit the pain. The goal here is that less pain information is transmitted to the brain. The therapy is not painful, so that the patient only feels a tingling sensation on the skin.

One advantage of this method is that patients can independently carry out applications at home using a rented or purchased device. Another widespread therapy is shock wave therapy. Here, attempts are made to stimulate the tissue with impacts and thereby achieve increased blood flow and regeneration of the tissue, which should ultimately bring about healing.

Shock wave therapy for Golfer's elbow

Shock wave therapy is used on the golfer's elbow when the usual conservative treatment options for the golfer's elbow have failed but you do not want to go as far as to perform an operation.

This form of therapy is now mentioned in the guidelines for therapy. However, there are still many who are skeptical about this type of treatment. The statutory health insurance companies unfortunately steadfastly refuse to take over this effective therapy.

How exactly the shock wave therapy helps with the golfer's elbow is not yet understood in every detail. However, it is suspected that the pathologically altered tissue structures on the affected muscle or tendon attachments are ground into tiny particles by the ultrasound pulses used, which trigger regenerative processes on the tendon.

In addition, the “shock” caused by the shock wave initiates repair mechanisms and stimulates blood circulation, which also helps the tissue to heal more quickly.

As a rule, extracorporeal shock wave therapy (ESWT) should be carried out on an outpatient basis for a golfer's elbow patient and without anesthesia or local anesthesia.

It works by covering the diseased area on the elbow with a contact gel. The shock wave head from the device, which resembles that of a kidney stone smashing device, is then directed onto the painful area and shock waves (ultrasonic waves / pressure waves) are directed into the affected area.

With the golfer's elbow, low-energy shock waves can normally be used for this, since the tendon attachments are relatively directly under the skin.

Many patients perceive shock wave therapy as a small blow, making the therapy uncomfortable. When done correctly, however, the treatment is otherwise hardly associated with complications.

Various smaller nerves and blood vessels run on the inner elbow, which are sometimes irritated by the shock waves.

So there may be bruising or pain in the area of ​​the treated area. In the worst case, if the treatment is not carried out correctly, damage to the elbow nerve (ulnar nerve) can occur, which can lead to impairments, especially when the fingers are spread and closed.

If the existing pain worsens as a result of the treatment and does not subside during the second or third session, you should stop the shock wave therapy and switch to one of the other therapy options.

The success rate is around 80%, which is quite high. However, it should also be noted that success depends on a number of external factors, especially the time at which therapy is started.

In an early stage, shock wave therapy helps more reliably than in a chronic stage. Nevertheless, it is a very effective method, especially for chronized golfer's elbow, which is becoming increasingly popular due to its few side effects and the good prospects of complete healing.

In some cases, it may make sense to use other methods to optimize the therapy in parallel to the extracorporeal shock wave therapy, for example physiotherapy or pain-relieving, anti-rheumatic medication.

Golfer's elbow Surgery

If after six months of treatment there is no improvement in the symptoms or even worsening, surgical therapy should be considered together with the attending doctor.

If there are no circumstances that speak against it, such as a lack of care at home after the operation or complications in connection with anesthesia in previous operations, it is usually possible to perform the golferelle bow surgery on an outpatient basis.

Furthermore, the operation is often minimally invasive, which means that the surgeon inserts his device through small skin incisions and that it is not necessary to open the joint completely. It should be noted, however, that the ulnar nerve runs near the affected joint and special care is required during surgery.

Some surgeons therefore still prefer conventional surgery to open the joint. Which procedure is used in individual cases must be decided with the attending doctor. Anesthesia can either be performed as regional anesthesia in a vein, as plexus anesthesia, i.e. anesthesia of all nerves in the armpit and thus of the entire arm, or in special cases also as general anesthesia.

A distinction can be made between two standard procedures when performing the operation.

With the Hohmann surgical technique, the origins of the muscles that attach to the elbow and cause the pain are severed. To do this, a small incision is first made on the elbow with the scalpel and the muscles underneath are exposed with their roots. Since the skin is very elastic, the cut does not have to be large. The surgeon can simply push the skin aside to see all of the important muscles. This enables the surgeon to recognize those muscle attachments that are under tension and are therefore responsible for the pain in the elbow. Now these tense fiber strands are severed and the arm is relieved in this way. Those muscle approaches that are relaxed and relaxed remain untouched and preserved, because they have nothing to do with the development of the pain. Once all the necessary approaches have been severed, the surgeon checks the free movement of the arm in the operating room and under anesthesia. It also tests whether a third person can see a dent near the elbow when a handshake is firm. This is usually the case. If the surgeon is satisfied with these two tests, the wound is closed again.

With the second standard technique after Wilhelm, the smallest nerves, which are responsible for the care of the elbow and thus for the transmission of pain in the golfer's elbow, are severed and obliterated. This process is also called denervation. A combination of both techniques is mostly used. Following the operation of 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 threads pulled, movement exercises should be carried out if there is no pain. In some cases, physiotherapy is also useful. The costs of such an operation are currently not covered by many statutory health insurance companies, so you should check with the respective health insurance company in good time.

Other treatment options for Golfer's elbow

Alternative healing methods / naturopathy

In the area of ​​traditional Chinese medicine, many doctors and therapists use acupuncture to treat the golfer's elbow.

A naturopathic approach is egg therapy.

The affected elbow is covered with leeches, which remain there for about 30-60 minutes until they fall off on their own. So far it is unclear how the effect of the gel therapy is achieved. The prevailing theory is that there are substances in the leech's saliva that help relieve inflammation. Egel therapy can not only be used to treat the golfer's elbow, patients with rheumatic diseases or osteoarthritis are also successfully treated with leeches.

Bandages

Sports bandages are able to immobilize the joint for some time and promise relief. Special elbow bandages ensure a protective position, but at the same time allow partial use of the joint.

TAPE treatment

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 the kinesiotapes takes place indirectly through the irritation of skin receptors on the muscles. Depending on the desired effect, various investment techniques are available. The system technology is determined by 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 strips on the skin. The tape should remain on for about 1 week, with the main effect expected in the first 3-5 days after application. Bathing, swimming and sports are also possible after the facility. Itching may be felt under the tape if this occurs if it is removed.

Drugs

Creams or gels with anti-inflammatory agents such as diclofenac are suitable for superficial use.

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 substances can cause irritation of the gastric mucosa, which is why other medications, e.g. Pantoprazole, must be taken.

Injections

There is also the option to inject painkillers on the affected elbow to relieve the pain. Cortisone is also suitable for injection and inhibits inflammation in the golfer's elbow. However, caution is advised because the area inflamed on the golfer's elbow is very close to the ulnar nerve. During the injection, the doctor injects the selected substance into the irritated tissue, making sure that he does not hit the nerve, as this leads to sudden stinging pain on the one hand, and the nerve may be damaged by cortisone on the other.

Forecast

The prognosis can be described as good, since most patients with a golfer's elbow disease are conservative, i.e. can be cured without surgery. However, the disease may occur over a long period of time and may only be healed with surgery. In rare cases, surgery cannot permanently relieve pain.

The golfer's elbow also occurs frequently with a tennis arm.

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