Orthopedics-Online

Therapy / treatment of tennis elbow

introduction

As part of the therapy of tennis elbow, various measures can be taken, which should be based on the severity of the disease, the individual suffering and the wishes of the patient.
General information about a tennis elbow can be found at: Tennis elbow

Conservative therapy

95% of all tennis arms can be completely free of symptoms with conservative measures.
Many different measures compete against each other. There is no such thing as the best therapy, but the treatment measures used must be tailored to the individual case.

Come as conservative measures

Relief / immobilization
However, complete immobilization of the elbow joint is contraindicated.
Bandages / cuffs / braces
You can find more about tennis elbow supports under our topic: Tennis arm bandage
Injections with cortisone and / or Zeel and local anesthetic
Cortisone can be injected locally (see also cortisone syringe). Cortisone is a steroid hormone that is derived from cholesterol. Like non-steroidal anti-inflammatory drugs, they have anti-inflammatory effects. The disadvantage of this application is that, although symptoms are rapidly alleviated (especially the pain), the spontaneous healing is delayed.
Shock wave therapy
Shock wave therapy should always be considered prior to surgery. The effect of the shock waves is probably based on the fact that regenerative processes are stimulated and this activates self-healing.
Please also read our extensive topic: Shock wave therapy for a tennis elbow
Tape treatment
Please also read our topic: Kinesio taping on a tennis elbow
Irradiation (X-ray stimulus irradiation)
acupuncture
Medication
Ointment treatment
Components of these ointment dressings are cortisone preparations or diclofenac-containing creams (e.g. Voltaren Emulgel), which have an anti-inflammatory and thus pain-relieving effect.
physiotherapy
Physiotherapy exercises should only be used when the patient is largely free of pain. It is important here to take sufficient breaks to exercise.
Manual therapy as part of physiotherapy: In the context of physiotherapy, treatment successes with so-called transverse friction, a special massage of the muscle tendons, are shown. The local blood supply to the tendons is promoted, the muscle tone is reduced, which results in total relaxation. Manual therapy also includes functional massages and extensive stretching of the extensors of the forearm (stretching muscles).
Please also read our extensive topic: Physiotherapy for a tennis elbow
Cold therapy (cryotherapy)
Cryotherapy is ideal for local pain relief. Cryotherapy is a medical treatment that uses cold. Local cryotherapy is used for swelling and pain relief.
Stretching exercises
Eccentric training is also recommended to keep the extensors (Extensors) to stretch. Eccentric training is characterized by the fact that a load is slowed down. As a result, the stressed muscles are not shortened, but rather stretched.
acupuncture
Leech treatment
Botulinum toxin treatment
If the symptoms persist, there is also the option of injecting botulinum toxin in low doses into the muscle.
After the injection, the neurotoxin paralyzes the muscle for two to three months, allowing it to recover. The effect then wears off. The symptoms should then at least be alleviated, if they have not even disappeared.
Unfortunately, there are no larger studies on the use of botulinum toxin in tennis elbow.

in question.
Minor damage to the tendon, so-called Microlesions, can be treated very conservatively.

If the focus is on pain, we have written a completely separate topic for this: Pain in a tennis elbow

Appointment with a tennis elbow specialist?

I would be happy to advise you!

Who am I?
My name is dr. Nicolas Gumpert. I am a specialist in orthopedics and the founder of .
Various television programs and print media report regularly about my work. On HR television you can see me every 6 weeks live on "Hallo Hessen".

As a former performance-oriented tennis player, I specialized early on in the conservative treatment of chronic tennis elbow.
In the last few years I have successfully treated several thousand tennis arms.

You can find me in:

Lumedis - your orthopedic surgeon
Kaiserstrasse 14
60311 Frankfurt am Main

Directly to the online appointment arrangement
Unfortunately, it is currently only possible to make an appointment with private health insurers. I hope for your understanding!
Further information about myself can be found at Dr. Nicolas Gumpert.

When is an operation necessary?

An operation is indicated when conservative therapies cannot eliminate the symptoms and tendon ruptures or a chronic course are present.
All conservative treatment measures should be unsuccessful for at least 6 months before surgical therapies should be considered.

There are several surgical procedures that can be used.
As a rule, however, a tendotomy can relieve symptoms. The different surgical procedures are shown below:

Operation according to Hohmann: The operation according to Hohmann begins at the radial Side of the elbow, i.e. on the outside. Here an arch-shaped incision is made about 5 cm in size. The muscle origins of the stretching muscles are then displayed and replaced. The incision of the tendons runs in a transverse direction, which is why the procedure is also known as a transverse incision. The elbow ligaments are also inspected. Changes (e.g. cartilaginous-bony adhesions) that can also cause pain can be removed.
Operation according to Wilhelm (denervation): The operation according to Wilhelm is the second standard procedure for treating tennis elbow. This procedure is mostly used in combination with the Hohmann operation. Here, small nerve branches that innervate (supply) the outer area of the elbow are obliterated. This operation is also used in the treatment of the golfer's arm.
Operation according to Goldie: The operation according to Goldie is similar to the procedure according to Hohmann. Here, however, the incision of the muscle tendons is not made transversely but longitudinally. Therefore, it is a longitudinal incision. This procedure is also often combined with the Wilhelm operation.
Minimally invasive therapy: A minimally invasive treatment is carried out by means of a maximum 1.5 cm long incision on the outside of the elbow. Here, too, the muscle tendons are notched, similar to the Hohmann operation. In very pronounced cases, however, a conventional surgical procedure makes more sense, as it allows the bones, muscles and ligaments to be better assessed and visualized.

Read a lot more information about this at: Operation of a tennis elbow

Duration of therapy

Unfortunately, tennis elbow therapy can take several weeks and months.Basically it is important to protect the affected arm for several weeks, and immobilization with a plaster splint may also be necessary. Conservative therapy should also consist of cooling the painful area and taking painkillers.

A short-term treatment success can be achieved by injecting local anesthetics, which inhibit the pain at its origin. It is also conceivable to inject corticosteroids into the inflamed area, which can inhibit the immune reaction and thus reduce pain.

However, it is possible that the symptoms persist or improve only slightly despite adequate immobilization and regular stretching exercises. If the symptoms are very severe and persist for six months, surgery can be considered.
Since every surgical procedure has risks and, in the case of tennis elbow surgery, the success depends on the indication, the method used and the experience of the surgeon, the question of an operation must be clarified with an experienced doctor.

Start therapy

The tennis elbow is usually treated conservatively.

As a rule, conservative therapy is started.
This means that you should first try everything to treat your tennis elbow without surgery. This works in almost all cases.
With correct therapy, the healing rate is 97%.
It is particularly important to protect the affected arm. Of course, the movement that caused the discomfort should be avoided, but other stresses on the arm should also be avoided as far as possible.

The conservative ways to treat tennis elbow

Treatment with a bandage

There is also the option of applying a bandage to a specific tennis elbow, which also "Epicondylitis brace" is called.
This is a bandage that usually has to be worn for several days and takes the strain off the sore muscles and tendons.

You can find more about tennis elbow supports under our topic:

Tennis arm bandage
Forearm bandage

Taping / kinesio taping

Tapes can help with sports and can be more individualized as an alternative to a bandage.
Kinesiotapes, which support healing and detonate the muscle, are much more common in conservative therapy.

Please also read our topic: Kinesio taping on a tennis elbow

stretch

Exercises to stretch the muscles affected by the inflammation in tennis elbow are very important to achieve a good treatment success. Patients can and should do these simple stretching exercises on their own.

With tennis elbow, stretching should be performed as often as possible in order to maintain the mobility of the affected muscles. Regular stretching also strengthens the attachment tendons and ligaments of a muscle. The stretching of the muscles in tennis elbow should not be carried out jerkily, but slowly and carefully.

At the Lateral epicondyle of the humerus employ five muscles:

M. extensor digitorum (Finger extensor)
M. extensor digiti minimi (Little finger extensor)
M. extensor carpi ulnaris (Ulnar hand extensor)
M. extensor carpi radialis (radial hand extensor)
and the
M. supinator (Forearm twister).

These muscles are responsible for stretching the wrist, stretching and spreading the fingers, and in some cases for slightly flexing the elbow joint.

stretching

Relief of the irritated tendon insertion is important for the tennis elbow to heal. The tension that is permanently on the tendon should be reduced. The main thing to do is to stretch the muscles mentioned above. In addition, overburdening activities must be avoided. To stretch, hold your arm forward with the elbow extended. The palm of the hand points towards the ground. Now bend the wrist and, if necessary, increase the resulting stretch by pulling or pushing the other hand. This allows the wrist extensor muscles to relax. This is repeated three to four times a day for about 4 x 20 seconds. Alternatively, you can lean against a wall with your arms straight. The fingers point to each other once inwards, once upwards and finally downwards. The palm of your hand is as smooth as possible against the wall.

In order to counteract permanent overload, attention should be paid to an ergonomic shape of keyboards and mice and break times, especially in everyday working life. In more severe cases, an experienced physical therapist can also help choose and perform the right exercises.

You can find more about stretching tennis elbow at: Stretching exercises for tennis elbow

Shock wave therapy for tennis elbow

The tennis elbow is a classic tendon attachment disease, caused by overloading and improper strain on the forearm extensor muscles.

Shock wave therapy has been proven to have a positive effect on this clinical picture if other measures, such as drug-based pain and inflammation therapy (NSAID / cortisone), transverse friction massages, physical therapy measures (electricity, etc.) have not led to the desired success. In any case, it is worth trying shock wave therapy before surgical measures are used.

In contrast to the calcareous shoulder, low-energy shock waves (or pressure waves) are often used successfully. This is due to the fact that the tendon tissue to be treated lies directly under the skin and is reached almost without being weakened by the low-energy shock waves. This presumably initiates regeneration processes that promote healing.

You can find further information under our topic: Shock wave therapy for a tennis elbow

Physiotherapy

Physiotherapy can also be useful. This includes certain stretching exercises that relieve pain and promote the healing process, as well as some special massage techniques, for example the transverse massage of the muscles of the wrist, which is also called transverse friction.
We have written our own topic on the subject of physiotherapy and tennis elbow. also read Tennis elbow and physiotherapy.

Treatment with locally applied ultrasound or microwaves can also reduce pain and can be used either alone or in combination with the massage in order to increase blood flow to the muscles before the massage.
Other options for more advanced cases are shock wave therapy.

You can find more information on our page: Medon - Exercises for the tennis elbow

Medication for tennis elbow

The next step in the course of treatment is medication.
Here, too, the doctor has different options which, depending on the case, are more or less useful for tennis elbow and should definitely be discussed with the patient before starting treatment.

First of all, dressings soaked with ointments that contain anti-inflammatory substances (e.g. Voltaren emulgel).
As an alternative, such preparations can also be taken orally (e.g. Voltaren, Arcoxia).
There is also the option of applying a mixture of such anti-inflammatory drugs and local anesthetics to the affected muscle attachment. The anesthetic is injected around the nerves, thereby blocking the nerve conduction and preventing pain.
In addition, classic painkillers are of course also used, especially from the group of anti-rheumatic agents (anti-inflammatory drugs = NSAIDs).
Alternatively, however, some herbal preparations (e.g. Zeel ©, Traumeel ©), enzymes, nucleotides or drugs can also be used to relax muscles.

Treatment with ointments

The painful tennis elbow can be rubbed with anti-inflammatory and / or analgesic ointments and bandaged for protection. Pain relieving ointments, however, are usually not a permanent therapy, because they only alleviate the pain. The advantage of ointments is that they (generally) cannot cause side effects that affect the whole body. On the other hand, you should be careful with the long-term use of pain medication and, if necessary, discuss this with your doctor.

Voltaren Emulgel

This frequently used ointment contains the active ingredient diclofenac. It belongs to the group of so-called non-steroidal anti-inflammatory drugs, which have anti-inflammatory and pain-relieving effects. This ointment is also recommended by the manufacturer for use on tennis elbow. The ointment should be applied to the affected elbow three to four times a day. If you still have to wear clothes, a light bandage will help. The amount used should be the size of a cherry to walnut (1-4g). As a rule, such an ointment dressing can be used for one to three weeks. Otherwise, the use should be discussed with a doctor.

Read more information on this topic at: Voltaren Emulgel

Cortisone

If the tennis elbow complaints are acute, an injection of cortisone into the irritated tendon attachment can provide rapid symptom relief.
This can last for a few weeks. However, today we advise against regular cortisone injections (cortisone injections) and the administration of chronic tennis elbow courses. This is due to the fact that cortisone can negatively influence the metabolism of the tendon and thus the permanent healing there. Therefore, the decision whether a therapy with local cortisone injections should be tried in the short term remains with the attending physician.
In the early stages, a cortisone injection is an entirely applicable therapy option. As the illness increases, the effectiveness of the cortisone injection decreases.
Systemic administration of cortisone should be viewed critically.

Read a lot more information on this topic at:

Cortisone injection
and
Cortisone

Are there any home remedies for tennis elbow?

A compress with quark can help with acute complaints: Smear a (kitchen) cloth with quark and then place it on the affected elbow.
The quark should come straight from the refrigerator if possible. If this has warmed up on the body, you can wash off the quark residues with water and repeat this process several times if necessary.
Other ointments, such as marigold ointment, can also be applied to the elbow. In addition, a hay flower bath for the affected arm relaxes and relieves pain. You can buy hay flowers in the pharmacy.

Should I use cooling or warming with a tennis elbow?

In the case of acute symptoms of the tennis elbow, it should be cooled in order to dampen the underlying inflammation symptoms. This will also reduce the pain. This can be done with the help of a cold compress (coolpack), a kitchen towel or something similar. wrapped around, happen. Alternatively, you can hold your elbow under running cold water. When cooling, care should be taken to ensure that the ice never comes into direct contact with the skin and that it is never cooled in one piece for more than 20 to 30 minutes. In the case of chronic disease, heat is more suitable, for example in the form of a cherry stone pillow.

The radiation for a tennis elbow

If immobilizing the tennis elbow in combination with the other options of conservative treatment does not lead to any improvement, radiation with X-rays can be tried. This therapy is also called X-ray depth therapy, because the X-rays can also penetrate the deeper structures of the elbow joint.

This treatment method is now covered by all health insurances and offers a cure rate of around 70%. For X-ray irradiation, very low individual doses of an average of 0.5 Gray are used; the irradiation is carried out two to three times a week over a period of a few weeks. Whether the treatment of the tennis elbow was successful with the radiation can only be assessed with a delay. This is because the pain may get worse at the beginning of treatment and the full extent of healing will not be achieved until after two to three months.

Exposure to x-rays triggers anti-inflammatory processes in the elbow joint and changes the immune response, so that, for example, excessive new tissue formation is prevented. It is also assumed that the pain receptors are directly inhibited by the X-rays.
Radiation with X-rays has almost no side effects, but it should be remembered that every radiation, just like every X-ray or every flight, means increased radiation exposure, which can increase the risk of tumors in the future.

Homeopathy for a tennis elbow

Various homeopathics are said to help with tennis elbow.

Homeopathy tries to heal diseases with the smallest amounts of substances that would cause similar symptoms in large amounts (similarity rule). The individual symptoms and characteristics of the patient are also dealt with and finally a herbal active ingredient in potentised form (i.e. highly diluted) is administered.

The homeopath will prescribe an individual therapy with an individual preparation of the globules for each patient. Commonly used active ingredients for tendon stiffness are Causticum, which is obtained from burnt marble lime and from potassium hydrogen sulfate, and Rhus toxicodendron, the oak-leaved poison sumac.

These are not naturally occurring especially for the treatment of tennis elbow Kalium bichromicum (Potassium dichromate, a salt of dichromic acid) and Symphytum (Comfrey) used. Arnica montana (Arnica) is used by homeopaths for chronic tennis elbow to reduce inflammation.

Read more on this topic at: Homeopathy for a tennis elbow

Acupuncture for a tennis elbow

In some cases, acupuncture is also helpful for tennis elbow, as it can not only reduce pain, but also directly counteract the inflammatory reaction.

Osteopathy

Osteopathy represents an alternative or supplement to conventional medicine in the therapy of tennis elbow. After a detailed discussion with the patient, the osteopath tries to feel and track down the functional disorder only through his hands. The disturbed function is also only treated with the hands.

From an osteopathic point of view, a functional disorder of the elbow in the sense of a tennis elbow can not only result from excessive or improper strain on the tendons of the forearm extensor muscles, as is assumed in conventional medicine. When treating tennis elbow, the osteopath also looks for causes, for example in the cervical or thoracic spine, and tries to correct them in order to remedy the cause of the tennis elbow.

One possible cause of tennis elbow from an osteopathic point of view is, for example, a misalignment of the ribs, which leads to a misalignment of the shoulder, which ultimately manifests itself in an incorrect position of the elbow joint and thus favors the overloading of the tendons.
A blockage of the cervical spine in the area of the nerve roots C5-C7, from which the nerves of the arm originate, is also conceivable. A blockage at this point will be released by the osteopath so that the tennis elbow can heal.

When is a cast needed?

As one of the last measures, a patient with tennis elbow can be put on an upper arm cast (elbow cast), which must be worn permanently and should prevent any movement in the joint.
However, this is already a significant limitation for everyday life and therefore not a permanent solution.
Studies on tennis elbow and cast have not shown convincing results.

When is an operation necessary?

If none of the above treatments bring any improvement in symptoms within 6 months, or if these may even worsen under the therapy, an operation may be indicated.
This only takes place in individual cases and must be carefully considered. An operation can normally be carried out on an outpatient basis and shows a good chance of recovery.
Here, depending on the surgical technique, either the affected muscles are detached from their origin (OP according to Hohmann) or the nerves that supply the corresponding area are desolated (OP according to Wilhelm).
Both can also be done together in one procedure. A new option is minimally invasive surgery, in which only a very small skin incision is necessary, the operation only takes a few minutes and the risks are minimal. However, this technique is still fairly new and is not yet offered in many medical practices.
After this mini-operation, the patient is immediately mobile again. According to the standard procedure, a cast must be worn for a certain period of time and the arm then slowly brought back to its normal load. Under certain circumstances, postoperative physiotherapy can also be useful.

In general, tennis elbow therapy shows very good success rates and patients can move freely again if they then conscientiously take measures to prevent a relapse.

You can find more information about tennis elbow surgery under our topic: Tennis elbow surgery

The tennis elbow in tennis players

Tennis elbow is the most common disease, which is why a tennis player needs to consult a sports orthopedist.
Approx. 20% all tennis players have already had an episode with a tennis elbow 3% suffer from a chronic variant.

A general distinction is made between a tennis elbow and a traumatic (accident-related) Genesis of tennis elbow, which is based on wear (degeneration) were created.

In the younger generation, problems at the muscle-tendon transition dominate, while in the older generation problems arise at the tendon-bone attachment directly at the elbow.

The causes of tennis elbow are varied. Usually, no real cause for the development of a tennis elbow can be identified.

The combination of several factors such as:

high intensity tennis (e.g .: media game season or LK tournaments)
faulty technology (especially with backhand and serve)
Change of club material (Change to a harder frame)
Change of stringing (Polyester strings must be mentioned as causing disease, as well as the increase in tension)
increasing age (the tendon attachment at the elbow becomes more sensitive to stress due to natural aging degeneration)
and
an unsatisfactory elasticity of the forearm muscles

are disease-causing.

For tennis players who suffer from a tennis elbow, treatment is more difficult than for a non-tennis player, since tennis is to be regarded as the cause of the disease.

In most cases, the person affected with a healed tennis elbow would like to give up his sport, so it is plausible that the recurrence rate (Risk of relapse) is particularly high among tennis players.

In addition to optimized therapy, causal prevention (Eliminating risk factors) particularly important.

The therapy of the tennis elbow contains three elementary parts. Passive, semi-active and active components must always be combined.

The passive elements include the transverse friction of the inflamed tendon attachment (special physiotherapeutic therapy method).
The semi-active components include targeted stretching of the forearm muscles.
Furthermore, the muscles and the tendon attachment must be actively strengthened through training.

At the same time, this three-stage therapy scheme is implemented through medication-based measures (Giving anti-inflammatory drugs orally or locally through an infiltration (syringe)) and physical measures such as stimulation current (TENS), Cold laser therapy and, for chronic cases, a focused shock wave therapy.

There is no general therapy guideline that tennis elbow should be treated.

The experienced sports orthopedist will take the following factors into account when recommending therapeutic measures:

Duration of illness (Acute up to three months, subacute up to six months and chronic for over 6 months)
Intensity of complaints
other stress factors for the elbow such as craft profession
Degree of damage (Inflammation of the tendon, inflammation of the bone, inflammation of the joint, partial tear of the tendon insertion)

The decisive factor in the therapy of tennis elbow is the application of the respective measure at the right time.
During an inflammatory stage stretch (the tennis elbow hurts particularly badly) is counterproductive, this measure becomes particularly important in the healing phase and prevention.

In general, anti-inflammatory measures are very helpful in the acute phase of the disease. However, these lose their effectiveness the longer the disease lasts.
In the chronic phase, regenerative therapy measures are used.

While tennis elbow is common in the acute phase in a few days can be treated in the absence of symptoms, a treatment in the chronic stage lasts mostly weeks, possibly months.

Surgical measures for tennis elbow play only a subordinate role and are usually only used for severe tendon damage.
Here, too, there is a wide range of open and minimally invasive measures. Which one should be used is based on the same analysis as for conservative therapy.

Once the tennis elbow has healed, it is important to reduce the tennis player's triggering factors.
The strain can be reduced with an elbow brace. A change of the tennis racket to a softer frame and a reduction in the tension of the string should also be discussed.
Finally, technical defects should be checked and improved by a tennis instructor.

An interesting fact on the side is that golfers are also more likely to develop tennis elbow than golfer's elbow.

Typically, the right-handed golfer gets a tennis elbow on the left side. For left-handers, it is the other way around.

The treatment strategy is the same for tennis players and golfers.
In general, golfers heal faster because the elbow strain is lower due to the lower number of strokes in golf.