The main cause of a tennis elbow is the overuse of the forearm muscles, which are responsible for the extension of the fingers and the wrist.
Overuse can be triggered by various factors. On the one hand, permanent, constant incorrect loads in everyday life, at work (e.g. screwing, grinding) and leisure (e.g. sport) can lead to overuse, as well as one-sided loads on the upper body (e.g. when using the mouse / keyboard at the workplace, during sport climbing, etc.).
Wrong techniques in stroke sports such as tennis or golf can lead to increased stress on the muscles of the forearm, as can certain arm positions during sleep (lying on one side, lying with the head on the elbow).
Differentiate painful tendon attachment points on the elbow in the context of other diseases such as fibromyalgia.
This is a chronic, incurable disease in which pain can repeatedly occur in changing muscles, joints and tendon insertions.
Symptoms of Tennis Elbow
The typical symptoms of a tennis elbow are:
- Pain on the outer side of the elbow
- Pain when grabbing the elbow
- Pain when lifting the wrist
- Pain when stretching the fingers
In addition to the typical pulling, burning and possibly radiating pain up to the upper arm on the outside of the elbow, which can occur both under pressure and at rest, there are other characteristic symptoms associated with a tennis arm.
Pain can occur especially when the elbow is stretched, as well as when rotating the forearm (e.g. when screwing) and when lifting heavier loads.
In addition to the pain, sensitivity disorders can also occur in some cases. Sensitivity disorders are feelings of numbness that are often limited to the area of the elbow, but in some cases can also affect the forearm.
With severe inflammation, external signs of inflammation can rarely be observed, such as redness, swelling and overheating of the elbow joint.
However, this is rarely the case with a tennis elbow, rather such symptoms indicate inflammation of the joint (arthritis) or the bursa (bursitis).
Typical of the tennis arm or tennis elbow is the pain, which can be triggered by pressure on the outside of the elbow - where the tendons of the forearm muscles attach - and on the other hand the pain, which is only increased by the movement of the affected forearm muscles. The pressure pain is caused by the local inflammation that irritates the tissue and skin in the area of the elbow.
The pain of movement is mainly provoked by finger extension and extension of the wrist (especially against resistance).
Sometimes even the fist closure or the turning of the forearm can hurt.
Specific localized symptoms of Tennis Elbow
Symptoms in the forearm
With a tennis elbow, the accompanying symptoms are mainly in the area of the forearm. The pain is mainly concentrated on the outside of the elbow, which can be triggered by pressure. In addition, pain occurs when fingers and wrists are stretched, often when the forearm is turned and turned.
In the beginning, the pain is often only felt in the area of the tendon of the elbow; when the disease progresses or if the muscles are strained, it can then radiate clearly into the forearm.
Symptoms in the upper arm
Depending on how severe the inflammation is in a tennis elbow, the pain can spread beyond the elbow.
In severe cases, the pain can radiate up to the upper arm even during exercise, certain movements or sometimes even at rest.
However, pain radiation is more common in the upper arm and forearm of the golfer's elbow, in which it is not the tendon insertions on the outer elbow that are inflamed, but the inside.
Here it can happen that the whole arm hurts.
Symptoms in the shoulder
If there is pain or painful movement restrictions in the shoulder in addition to the pain in the elbow, this can sometimes be a sign that there are incorrect loads, incorrect postures or incorrect movements in the area of the upper body.
A severely inflamed tennis arm can in some cases even lead to pain radiating to the shoulder; the other way round, a painful shoulder can also lead to incorrect posture and incorrect strain in the forearm muscles, which in turn can cause a tennis arm when overloaded.
General symptoms of Tennis Elbow
As a rule, the tennis elbow or tennis elbow is not accompanied by a feeling of numbness or by so-called sensitivity disorders (e.g. tingling sensations). Only when the disease is very pronounced can the skin feel slightly numb in the area of the outside of the elbow or on the outer forearm down to the wrist.
The reason for this is assumed to be that the inflammatory process on the elbow leads to simultaneous irritation of the skin nerves running along it. If, on the other hand, there is complete numbness of the hand or individual fingers with a tingling sensation, other, possibly more serious diseases should be considered (e.g. herniated disc, carpal tunnel syndrome, sulcus ulnaris syndrome, etc.).
If a tremor occurs for the first time in the context of a tennis arm and the tremor is limited to the side affected by the inflammation, there is no need to worry at first, since the tremor in this case is most likely due to the tennis arm.
Due to the overused muscles and the stressful pain, the forearm muscles in particular are quickly fatigued and more easily overused. This muscular exhaustion can cause tremors in the hand, arm, or fingers. This is comparable to a tremor after heavy muscle strain due to training, e.g. Strength training.
Tennis Elbow diagnosis
In order to be able to diagnose the tennis elbow, the doctor treating the patient begins by taking a medical history, i.e. taking a medical history, focusing on the characteristic pain symptoms.
The elbow is then examined, whereby pressure pain on the outside as well as reddening, swelling, overheating or even gentle posture can often be noticed.
Often the diagnosis can already be made, if there are still doubts, further clinical tests can follow: firstly, the stool test, in which the patient has to lift a chair with the arm extended and the forearm turned inwards; on the other hand, the Thomson test, in which the hand is closed to a fist and the wrist is to be bent back against resistance (further tests: Bowden test, Mill test, Cozen test).
In addition, blood tests can confirm signs of inflammation (CRP, blood sedimentation rate, increase in leukocytes). Ultimately, various imaging methods can also be used to settle uncertainties in the diagnosis: an ultrasound examination of the elbow, an X-ray of the arm and / or magnetic resonance imaging (MRI) can be used.
MRI on a tennis elbow
As a rule, the tennis elbow can be put down solely by taking the medical history, i.e. by talking to the doctor and the patient, and by following the physical examination, i.e. by examining the elbow, by the treating doctor.
If the examination result is not entirely clear, the doctor can use imaging, in addition to the X-ray and ultrasound examination, magnetic resonance imaging (MRI elbow) is also used. With the help of the MRI from the elbow, soft structures can be displayed particularly well, including the tendons and muscles on the affected elbow. The degree of inflammation can then be determined and possible complications such as muscle / tendon tears can be excluded.
How is a tennis elbow treated?
The treatment of the tennis elbow can be divided into a conservative and an operative one.
It usually starts with conservative therapy, which in addition to sparing and possibly immobilizing the elbow joint also includes regular cooling. Ointments (bandages) containing painkillers or cortisone, bandages or cuffs, physiotherapeutic treatment (strengthening training, stretching exercises, massages etc.) and acupuncture are also among the conservative treatment measures.
Syringes containing a mixture of local anesthetic and cortisone can also be injected locally into the area of the elbow.
Painkillers can also be taken as tablets, with preference given to non-steroidal anti-inflammatory drugs (NSAIDs, e.g. diclofenac, ibuprofen), which have an analgesic effect as well as an anti-inflammatory effect.
If there is no success in conservative therapy, the step can be taken to surgical therapy, whereby there are various methods to relieve the tennis elbow.
Another therapy attempt for chronic complaints is the injection of botulinum toxin (also known as botox) into the muscle in order to "paralyze" it for 2-3 months so that it can recover.
Bandage / Brace
One way of conservative therapy of a tennis arm is to put on and wear a tennis arm bandage or tennis arm clip.
Therapy with a bandage or brace plays a very important role in the acute phase, while the two aids become less efficient in the chronic phase.
If the tennis elbow is still in place, this can help to relieve the strain on the muscles affected and heal, along with cooling, protection, pain relievers, physiotherapy and stretching exercises, but also prevent recurrence after successful therapy and the continued heavy strain on the forearm muscles.
A bandage / brace does not restrict the freedom of movement as consistently as, for example, a plaster, but rather guarantees an unrestricted range of movement.
The purpose of such a bandage / brace is to exert targeted pressure, concentrated on the attachment point of the tendons on the elbow, which means that the muscles of the forearm are relieved and pain can be alleviated.
Such cuffs can be purchased over-the-counter in a wide variety of sports shops and medical supply stores, but advice should be sought from the attending doctor beforehand as to which type of bandage / brace is best suited. You should also pay attention to the correct size and fit, as otherwise even uncomfortable symptoms can be caused by a bandage that is too tight and tied off.
Your doctor will be able to tell you whether you will 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 exercise (on sports, on the PC) to relieve the tendon. Where the elbow is not subjected to stress, bandages or the like should not be worn, as this interferes with the healing process due to the compression.
Taping in the context of a tennis elbow can also be viewed as a supportive therapeutic measure and support conservative treatment, i.e. non-surgical treatment.
You can tap both with elastic tapes (e.g. Kinesio tapes) and with non-elastic tapes (e.g. Leukoplast).
Elastic kinesio tapes are used to support healing. Inelastic tapes help athletes to be less painful during sports.
Which type of tape should be used depends entirely on what exactly is to be achieved with the tape: inelastic tapes have a rather "shining" function - similar to bandages or fixed pull bandages - they therefore restrict the range of movement in the elbow somewhat and support the keeping calm.
Elastic tapes (kinesio tapes), on the other hand, restrict the movement less or not at all, support the movements at most and promote or activate the blood circulation, the underused muscles and the lymphatic drainage, so that pain relief, swelling and inflammation control can occur.
The tapes should always be applied or glued by experts, as tapes that are incorrectly glued or stuck too tight can also lead to further complaints, e.g. Circulatory disorders.
Stretching exercises can be carried out during an acute tennis arm and contribute to healing, but they can also be used regularly after the tennis arm has been used in order to prevent recurrence.
For example, the following exercise can be carried out 2-3 times a day: The arm is stretched straight forward from the body at a 90 ° angle, and the elbow should not be bent. With the palm facing upwards, the hand in the wrist is now bent down and held in this position with the other hand for approx. 30 seconds.
Exercises with the Theraband
Exercises with the Theraband are a popular way to treat the complaints of a tennis elbow. By using the Theraband, the tendon is stretched and stressed. If used correctly and regularly, this can heal the disease and significantly alleviate the symptoms.
Thera Band's flexible exercise stick is gripped 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 starting position.
Important: No pain may arise during the exercises. Exercises are measures in the treatment that support healing and are rather harmful in the acute phase of the tennis elbow!
Another therapeutic option is to give a syringe in the area of the inflamed elbow joint, this syringe consisting 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 a tennis elbow. An isolated cortisone injection can no longer help in phases of a chronic tennis elbow.
The side effects of a local cortisone injection are usually manageable and are often overestimated by those affected. Tendon tear - as often described elsewhere - I cannot confirm as a practitioner of thousands of tennis arms when used correctly. Nevertheless, the use of the cortisone syringe is not the first choice.
Shock Wave Therapy
Shock wave therapy, like radiation, is part of a non-invasive therapy option for the tennis elbow, i.e. therapy that does not penetrate, i.e. does not open the body surface, as would be the case in an operation.
This procedure is used by various orthopedic surgeons to treat severe, protracted, chronic tendonitis.
Strictly speaking, the 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 energy transfer. This pressure is intended to irritate the respective tissue, as well as stimulate the blood circulation and cell metabolism and promote complex healing processes.
Pain symptoms can also be reduced by using shock waves, but the exact mechanism of action in all its details has not yet been deciphered exactly.
Shock wave therapy is an efficient reserve procedure if other therapy methods have failed or the complaints persist for more than 6 months.
As with all therapy methods, the success of the shock wave treatment depends in particular on the experience of the user.
Tennis elbow surgery
In the tennis elbow, surgery is only useful as therapy in some cases.
First of all, treatment should always start conservatively. Surgery should only be considered after 6 months of conservative therapy if there are no significant improvements in symptoms or the condition of the person concerned has even worsened.
However, there are, of course, other factors influencing the decision as to whether the operation will actually be carried out, especially the patient's individual suffering. Ultimately, the aim of the operation is to achieve a permanent relief of the chronically tense muscles and to give the person affected his unrestricted, painless freedom of movement.
As a rule, a tennis elbow operation can be performed on an outpatient basis, which means that the person concerned does not have to be admitted to the hospital.
Minimally invasive techniques are also developing in tennis arm surgery, so that a tennis arm operation can now be performed under local anesthesia.
In principle there are three different procedures to operate a tennis elbow:
- The standard procedures are the Hohmann operation
- The operation after Wilhelm
- The latest technique is the minimally invasive operation according to Hohmann (Burke)
During the Hohmann operation, the muscles or tendons that arise in the area of the elbow (on the upper arm bone) are carefully removed.
The ligaments that attach to this area are also carefully examined in order to remove any bony changes that may also be present, which also contribute to the symptoms of a tennis elbow.
Operation after Wilhelm
During the Wilhelm operation, the small nerves that supply the elbow with sensitive tissue are severed and then desolated.
This is known as "denervation". These two surgical techniques (Hohmann-Wilhelm surgery) are often combined.
The cut size is usually about 4 to 5 cm and the whole procedure takes about 20 - 45 minutes.
After such an operation, the affected arm must be immobilized for a while. This is usually ensured by placing a plaster splint on the patient, which the patient must wear for about two weeks. However, a plaster cast is not mandatory.
Then you should slowly start moving the elbow in the joint again.
Depending on the healing process, it is advisable in some cases to include professional physiotherapy in the aftercare.
Minimally invasive surgery
The minimally invasive operation differs from the two above in some important points.
The procedure can be completed within 5 minutes and is always done on an outpatient basis, although there are not yet many medical practices in Germany that use this method.
Here the skin incision is less than 1 cm long. On the one hand, this means that the risk of infections and scars is reduced. On the other hand, the overview for the orthopedic surgeon is also less and some ossified areas that are a little further away from the origin of the muscles may be overlooked.
The main advantage of this type of surgery is that the patient is immediately mobile again. A pressure bandage only needs to be worn on the first day after the operation. The fact that the arm is hardly kept still means that less scar tissue is formed and the loss of function is limited in most sufferers to postoperative pain, which cannot be avoided after every type of operation and within 3 to 5 days depending on the physical condition should have subsided.
Complete freedom from pain can be expected after 3 weeks to 6 months, depending on the severity of the tennis elbow and the healing process. The chances of success with this surgical technique are almost 90%.
Relapses / recurrences after tennis elbow surgery are rare and can then be addressed conservatively and / or surgically.
In these two conventional procedures (surgery according to Hohmann / surgery according to Wilhelm), the operation is carried out under anesthesia.
Depending on the case, this can be general anesthesia, regional anesthesia or plexus anesthesia (anesthesia in the armpit).
The minimally invasive form can be performed under local anesthesia.
The risks of this operation are primarily due to the relatively large incision and the associated high probability of infecting the wound postoperatively or causing pronounced scarring that affects movement and cosmetics in the long term.
Complete healing is achieved with open procedures (Hohmann OP / Wilhelm OP) in about 80% of cases.
An important point is that the so-called supinator box syndrome should always be excluded before the operation of a tennis arm. This syndrome leads to pain that is very similar to that of a tennis elbow and is due to the fact that a branch of a nerve (superficial radial nerve) is trapped in the muscle artery of the supinator muscle in the forearm area.
If these two clinical pictures are confused, the tennis elbow surgery does not bring pain relief. Often, however, both diseases are present in parallel, and the tennis elbow operation can then be combined well with the open procedure common in supinator box syndrome.
Radiation in the context of a tennis arm is the so-called X-ray stimulation radiation.
As the name suggests, X-rays are used, which are directed to the area of the elbow and is a long-established method for treating inflammation of tendon insertions. Like a surgical operation, the irradiation of a tennis elbow is only a reserve therapy that can be used after at least 6 months of unsuccessful conservative therapy.
Mostly 6 treatments are carried out, 2 of them in a week. Often, the symptoms only worsen during the treatment, which is not a bad thing, however, but rather means that the treatment responds well. The final result, i.e. the alleviation of the symptoms, often only occurs 3-4 months after the last radiation.
Duration of a tennis elbow
It is not always possible to say generally how long the symptoms of a tennis elbow last, it depends on a number of factors that influence the course of the disease.
In addition to the correct, accompanying therapy, the consequent immobilization of the elbow and the protection are largely responsible for the healing.
Nevertheless, the tennis arm is often a persistent discomfort that can persist for several weeks despite therapy. These should then be treated symptomatically with cooling, pain relievers and any syringe with cortisone and local anesthetic.
The immobilization can be done either independently or by a bandage, a tape or even a plaster.
If the symptoms persist for more than six months, then one speaks of a chronic tennis elbow, in which it may be possible to consider an operative therapeutic procedure.
Unfortunately, you cannot quantify the exact duration of a tennis elbow. A tennis arm that exists for a few weeks can usually be healed in 2 weeks.
Chronic tennis arms sometimes take months to become pain-free and fully resilient again.
Accordingly, the duration of a sick leave is difficult to predict. Someone who works in the office usually benefits from a week's workload. For artisans, a sick leave can take several weeks.
The same applies to an operation. With an office worker, working capacity with minimally invasive technology is reached in 14 days. Someone who has to lift heavy workdays can fail many weeks in an open surgery.
Most of the time, the tennis arm has a good forecast. Many patients can be treated conservatively with one disease, i.e. surgery is not necessary in most cases. 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 prognosis of the tennis arm is mainly influenced by the inflammation of the common extensor tendon (ie the "extensor vision").
It is prognostically unfavorable if there is a tear in the common extensor tendon (on the tennis arm). Basically, torn tendons can also heal with optimal post-treatment.