Orthopedics-Online

Physiotherapy / physiotherapy for a tennis elbow

Goal: functional training
Strengthening of the forearm muscles and the entire arm muscles
Posture training
Exercise example strengthening the shoulder blade muscles

Note

You are on a subpage of our more extensive page tennis elbow.

Synonyms

Tennis elbow, Tennis elbow, tennis elbow, epicondylitis humeri radialis
English: tennis elbow

introduction

This topic is about the physiotherapeutic treatment of tennis elbow as an important and promising component of conservative therapy, which unfortunately, due to increasing budgeting by doctors, especially in the field of orthopedics in the therapeutic area, is used far too rarely.
Studies have shown that the importance of physiotherapeutic treatment in relation to the success of healing with other therapy options such as:

medication
Cortisone infiltration
acupuncture
Shock wave etc.

is at least equivalent, and that the therapeutic success is even more lasting in the long run.

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.

Diagnosis

The diagnosis of the tennis elbow and the differentiation from the so-called golfer's arm, in which the pain is localized on the inside of the elbow, is essentially carried out by questioning the patient and using special manual test procedures, which will be discussed in more detail later. This form of diagnosis can be carried out by the physiotherapists, who rely on their senses (eyes, ears, hands) during the examination and therefore have a lot of experience in manual examination techniques, while the doctors also have access to the diagnostic procedures using apparatus.
The physiotherapist does not use the test procedure to make a diagnosis, but as an instrument for re-evaluation after treatment.

1. History - anamnesis

Most of the patients are between 30 and 50 years old.
Pain indication over the outer joint part of the elbow, radiating in hand or upper arm.
Restricting normal everyday movements, even shaking hands or lifting a coffee cup can lead to severe pain in the acute stage.
In most cases, this was preceded by an overuse of the forearm extensor muscles. It doesn't necessarily have to be Play tennis be, occupational overload can also be present. Particularly one-sided, monotonous, unfamiliar activities that involve a lot of effort are a frequent cause.
Often the patients have already passed a phase of acutely painful inflammation when they are referred to the physiotherapist.
Later: loss of strength in the entire arm muscles.
roentgen / CT (Computed Tomography) /MRI (Magnetic resonance imaging) / Ultrasonic (Sonography) or laboratory values are mostly normal, especially in the acute stage.

2. Special test procedures for diagnosing tennis elbow

Chair test

The patient is asked to stretch out elbow to grab the back of a chair from above and lift the chair. If the patient reports a known pain in the outer area of the elbow during this process, the test is positive.

Thomsen test

The patient should raise their hand against the resistance of the therapist with the elbow extended. If the typical pain is triggered, the test speaks for an existing tennis elbow syndrome.

Middle finger extended

The patient is asked to stretch his middle finger with the forearm on against the resistance of the therapist. If the pain is known to be provocable, the test is positive.

Another test

The patient is asked to turn his forearm from "inside to outside" against the resistance of the therapist, so that after the movement has taken place the palm of the hand looks up. (Receive tip) This test is also positive if the pain is aggravated by moving the forearm against resistance outer elbow occurs.

The test procedures described are so-called Provocation testsi.e. the examiner tries to evoke the patient's “known” pain through a certain posture or movement.
The stretch-side Musculature is examined for pain and loss of strength during tension.

3. Palpation

More detailed information about the affected tissue structure (Musculature, Tendon, tendon attachment) can be accessed via the Palpation (palpation) determine. The bone attachment of the affected muscles and the forearm muscles in their course on the back of the forearm are extremely painful on pressure. Often you will find painful areas on the inside of the Elbow in the area of the muscle attachments of the forearm flexor muscles.

Not all tests have to be positive to make a diagnosis. The extensor muscles of the wrist are most frequently affected.

These tests in connection with the questioning of the patient are nevertheless so conclusive that in most cases an involvement of the shoulder joint or cervical spine can be excluded. The tests are also important for Re-evaluation of the patient to make a statement about the Treatment success of the Physiotherapeutic treatment to get.

4. Further manual examinations for differential diagnosis

Manual therapeutic examination of the elbow joint for restricted mobility. This can be triggered indirectly by the rest, but it can also be directly responsible for the inflammation of the extensor tendons on the elbow.
Manual examination of the shoulder and wrist.
Manual examination of the cervical spine on functional disorders and irritation of nerves, segments C6-TH1 (6th cervical vertebra - 1st Thoracic vertebrae) affected. These can lead to the radiation of pain into the elbow region or to the intensification of already existing pain symptoms.

5. Posture findings / body statics

As a last important point of physiotherapeutic assessment I would like to name the survey of the posture findings. A persistent bad posture on the part of the patient, resulting in "Hunchback“, Shoulders pulled forward and upper arms turned inwards (predominantly sedentary lifestyle), can lead to the development of the clinical picture as a contributing factor via changes in tension in the muscles and a decreasing pain threshold due to the constant stress posture.

forecast

Stage 1

The acute epicondylitis usually sounds with rest and physical measures such as:

Cold, (less often heat applications),
Electrotherapy (tens or ultrasound),
MTC = Medical Taping / Kinesiotaping, (see treatment in stage 2/3).
Transverse tendon friction (possibly from about the 5th day of the symptom) and local medicinal applications such as Ointments with anti-inflammatory active ingredients, disappear again within a few days to about 3 weeks.
Possibly, even in highly acute cases, a temporary immobilization of the splint with accompanying physiotherapy can provide relief.
In addition, after immobilization, an epicondylitis brace or tennis arm bandage can be given. It is important to attach the brace / tennis arm bandage exactly, as it is pointless if it slips or is incorrectly positioned. The brace relieves the muscle attachment of the muscle on which the brace pad is attached and can still be worn during stressful activities even after the acute phase has subsided.
Information: The therapist explains the clinical picture to the patient and discusses the possible cause, the expected course and the therapeutic options with him.
In any case, it makes sense to get rid of the possible cause of epicondylitis, i.e.
Examination and conversion of the workplace according to ergonomic aspects (sometimes it is enough to switch the mouse on the PC to the other hand or use a vertical mouse)
the use of a relieving forearm splint on the PC, height adjustment of the chair or desk, the use of a cordless screwdriver for the IKEA furniture
Suspension of stressful activities such as Tennis, gardening, playing the piano, possibly short-term sick leave with high occupational stress, etc., in order to achieve pain relief.
Fear of reduced performance and frustration due to possibly unsuccessful treatment attempts can make the disease more chronic. For this reason, information about the prognosis, targeted acute treatment to avoid chronification and the involvement of the patient in the therapy process are very important, especially in the acute phase of the tennis elbow.

Stage 2

The patient has pain at rest and when moving, the pain hinders him in everyday life and in the exercise of his job. At this stage, passive and active physiotherapy measures are used.

Stage 3

The pain becomes significantly stronger, persists before, during and after exercise, and only disappears if you take absolute care.
In most cases (approx. 80%) the epicondylitis heals completely in the acute stage or in stage 2-3.

Physiotherapeutic therapy in stage 2, possibly 3

When treating the Epicondylitis In stage 2/3, a variety of local treatment methods are available to physiotherapists, always provided that the cause of the pain really lies in the elbow area. There are already multiple studies, which, however, cannot clearly confirm a treatment method as absolutely effective and unambiguously as the means of choice. I will therefore list the various therapy options based on experience and frequency of use. Ultimately, the therapist must select the treatment method based on the individual patient findings and the success achieved after a trial treatment.

Physiotherapy measures after the acute symptoms have subsided

Goal: Pain Relief

When selecting the treatment techniques, I refer to the diagnosis of "tennis elbow" made after differential diagnosis and do not go into the treatment of other possible causes of pain (cervical spine, thoracic spine, shoulder joint).

MTC medical taping / kinesio taping

With medical taping / kinesio taping, elastic functional tapes are applied to the forearm in a specific form.
This mainly serves to relieve the muscles and improve the metabolism, so that the inflammatory processes (edema formation in the inflamed area) can be broken down more quickly.
With a tape system (even in the acute stage), rapid pain relief without side effects can often be achieved. The kinesio tape stays on the skin for about 7 days and should be worn continuously for an average of 4 weeks.
It offers good support for the forearm extensor muscles, especially during strenuous activity, and can be used as an alternative to the epicondylitis brace or tennis arm bandage.

Read more on this topic at: medical taping / kinesiotaping for a tennis elbow

Transverse friction and myofascial soft tissue techniques

In the Cyriax transverse friction massage the tendons of the affected elbow extensor muscles are massaged across the tendon under intermittent pressure and tension. In addition, a Cold therapy (Cryotherapy) to stimulate blood flow and reduce inflammation.

Bonding the tendons are eliminated.
on the The edema drains off the inflammation reduced.
Pain relief is achieved.

A prerequisite for this therapy is a precise examination of which tendons and in which area the affected structure (muscle tendon transition, muscle bone transition) must be treated. The physiotherapist should also examine whether there are other treatable soft tissue affections in the area of the inside of the elbow (elbow flexor muscles, so-called golfer's arm), shoulder and cervical spine, which are constantly maintaining the pain picture.

Both myofascial soft tissue techniques muscles and connective tissue are relaxed with very soft holding and shifting techniques. They can also be conveyed to the patient at home (helper is desirable).

Elongations

The stretching exercises should be carried out several times a day as a home program after successful pain relief from the physiotherapist.

Important: exact implementation and dosage!

They are controversial as an application, as some patients react with increased muscle tension and increased pain. Personally, I have had mostly positive experiences with stretching exercises as an effective therapy tool for tennis elbow and would definitely carry out test treatments to test the patient's stimulus-response behavior.
The main target muscles are the wrist extensor muscles, or in exercises 2 and 3 the rotary movement in the elbow joint is mobilized.

Forearm extensor stretching

Exercise example stretching forearm extensor muscles

The back of the hand is placed as completely as possible on a table with the elbow extended and held in this position.

The palm of the hand is supported on a table with the elbow extended, the elbow joint is rotated inside out and back.

Stretching the chest muscles

Exercise examples stretching the chest muscles

In the first exercise, both sides of the chest muscles are simultaneously stretched and the thoracic spine is mobilized in extension; in the second exercise, one-sided stretching and the thoracic spine are mobilized in rotation.

The physiotherapist will give precise instructions on how to do it in terms of dosage, intensity (caution required), frequency / day and repetition / exercise.

Manual therapy: lateral sliding:

The lateral sliding is a technique from the Manual therapyin which the physiotherapist gently slides the forearm outwards against the humerus with the upper arm fixed. Meanwhile, the patient opens and closes his fist several times. This technique should be used when the patient responds positively to a trial treatment.

Goal: functional training

The physiotherapeutic measures in the further course of treatment in the build-up and functional phase are used for rehabilitation. The Musculature must come back on after the inflammatory process has subsided
be prepared for their normal everyday stress at work and in their free time.

Strengthening of the forearm muscles and the entire arm muscles

In the long run you get what is known as isotonically eccentric Exercises (Isotonic eccentric muscle work means that the muscle brakes a weight in its falling motion) the best results for the wrist area.

Exercise example strengthening the forearm extensor muscles:

A dumbbell is slowly lowered over the edge of the table, the weight increases with the healthy one poor brought up again so that the affected muscles do not have to work concentrically (that means for the muscles to build up strength against gravity).

Exercise example strengthening arm muscles:

The arm is lifted with the healthy arm from the bottom inside to the top outside and slowly holding it is lowered back to the starting position.

Posture training

Bad posture, especially over a long period of time, e.g. Working posture at the desk has a negative effect on the development of epicondylitis radialis humeri (tennis elbow). In the long run, a hunched back posture and the resulting forward shoulder position cause a painful muscle chain From the shoulders to the arm, certain muscle groups shorten and the position of the shoulder joint head in the joint and the shoulder blades changes. The physiotherapist uses perceptual training to make the patient aware of his bad posture and shows simple exercises Improvement of Posture.
Be parallel Stretching exercises for the shortened muscle groups in the upper body and shoulder area and Strengthening exercises Mainly performed for the back muscles of the shoulders and back and the deep abdominal muscles.

Exercise example strengthening the shoulder blade muscles

A Theraband is pulled apart from an upright position behind the back.
Many of these exercises can be taught in such a way that they can be easily integrated into everyday life and at work. Again the therapist gives precise instructions on how to carry out the exercise program.
Note: Think about the posture 200 times / day!

Here you can get information on the topic Expander training

Sports physiotherapy

In the rehabilitation phase, sports physiotherapy can be started primarily as prophylaxis (prevention of disease recurrence = recurrence of the disease). The focus is on checking and correcting the technique (tennis, possibly golf for the golfer's arm), slow training build-up, consistent warm-up, stretching exercises and possibly advice on changing materials.

Example: At Tennis serve Approx. 50% of the strength is required from leg and trunk muscles, but only approx. 25% from arm and hand.

If the coordinative process of this muscle chain is not correct, the elbow and wrist are quickly overloaded and the development of a tennis elbow is encouraged.

Stage 4

There are permanent strong, sometimes stabbing pain often also at night, there may be irreversible (irreversible) tendon damage, in the worst case the extensor tendon can tear.
In stages 3 and 4 of the tennis elbow, conservative therapy is only of limited use, and surgery may be indicated. The transitions between the individual stages are fluid.

Summary: functional therapeutic approaches

The overall functional treatment concept for chronic epicondylitis radialis humeri is decisive for long-term therapeutic success.

No Dawos treatment! does not only mean paying attention to the local pain occurrence during examination and treatment - where it hurts - but also considering and treating the patient's problems as a whole.

Recent studies support a more global treatment concept in terms of long-term treatment success!