Epicondylitis

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Classification according to ICD-10
M77.0 Epicondylitis ulnaris humeri
M77.1 Radialis humeric epicondylitis
ICD-10 online (WHO version 2019)
Epicondyle lateralis humeri

Epicondylitis (also epicondylopathy ; epicondylosis or epicondyalgia ) is an acquired, painful irritation of the tendon attachments of the muscles of the forearm, which arise on the two protruding bones above the epicondyle on the distal part of the humerus . The disease is assigned to the group of enthesopathies .

The so-called tennis elbow

There are two forms:

  • Epicondylitis radialis humeri (also tennis elbow ; tennis elbow or epicondylitis humeri lateralis ): on the outer epicondyle of the humerus ( extensor of the wrist and fingers).
  • Epicondylitis humeri ulnaris (also golfer's elbow , golfer's elbow or epicondylitis medialis ): the inner epicondyle of the humerus ( flexors of the wrist and fingers).

causes

Epicondylitis is caused by overuse of the forearm muscles. Possible triggers are:

  • One-sided stress (e.g. when using the keyboard / mouse, see also: Repetitive Strain Injury Syndrome , Sport Climbing )
  • Bad posture at work, in housework, gardening or in leisure time
  • wrong technique in racket sports (the grip circumference does not matter)
  • Sleep position in the side position (use of the strongly bent arm as a headrest)
  • tendotoxic effects that may occur in connection with the use of fluoroquinolone antibiotics

Diseases such as fibromyalgia also show spontaneous pain in the muscles in the course of tendons and tendon attachments and can have pressure points (tender points) on the elbow. They must be differentiated from epicondylitis in the context of the differential diagnosis. (In the past, epicondylitis such as humeroscapular periarthritis were viewed as a local manifestation of "soft tissue rheumatism").

In recent years, the importance of other causes of pain in the lateral epicondyle has become much better. It has been shown that, particularly in chronic cases, one of these differential diagnoses is often the cause of the persistent pain. Important differential diagnoses are:

  • Elbow instability: An instability of the external ligament apparatus leads to increased opening of the elbow and pain. The extensor muscles of the forearm try in vain to compensate for this and become overloaded. This leads to an intensification of the pain.
  • Nerve compression: the deep branch of the radial nerve can become pinched and painful. Because of the physiology of this branch, a nerve conduction velocity measurement can be false negative.
  • Pinching of mucosal folds: A fold of the mucous membrane ( plica ) in the elbow can pinch painfully.
  • Cartilage damage: In children, the articular cartilage can spontaneously detach from the capitulum, a so-called osteochondrosis dissecans . But even after a radial head fracture , cartilage damage can occur, which causes pain in the lateral epicondyle.
  • Osteoarthritis: Chronic cartilage damage and osteoarthritis can also cause pain in the lateral epicondyle.

Symptoms

Typical is a circumscribed pressure pain over the muscle attachment at the elbow and a pain triggering or intensification when exercising these muscles.

Therapies

In addition to physiotherapeutic procedures, there are also therapies such as waiting, cooling with ice, muscle strengthening exercises, arm slings , bandages , bandages, radiation therapy (X-ray stimulus treatment - recognized by health insurance companies), shock wave therapy (ESWT and lithotripsy ), the use of diclofenac- containing creams and Gels, manual therapy ( e.g. cross friction according to James Cyriax ), local friction massages and the injection of cortisone . If conventional therapy methods do not provide any or no permanent relief from the symptoms, there is still the option of using botulinum toxin therapy as offlabel use before an operation . Diseases of the cervical spine should also be checked during the initial examination, but at the latest if the therapy is unsuccessful, e.g. B. Damaged intervertebral discs (especially level C5-7), foraminal stenoses at this level or clinical predominantly functional disorders of the lower cervical and thoracic spine , here then chiropractic and / or physiotherapy as a therapeutic consequence.

Studies with physiotherapeutic procedures (stretching exercises, physiotherapeutic training) suggest that these may be superior to others in some respects. A corresponding break from stress is important for healing. Physiotherapy exercises should also usually only be carried out when the pain has largely subsided. Complete immobilization, on the other hand, is not necessary and in the long run can even cause recurrence.

In the case of resistance to therapy, surgical therapy can be used. In the area of ​​the epicondylus radialis humeri (tennis elbow), the Wilhelm-Hohmann operation is usually used. This relieves the muscle tension by partially severing the tendon attachments at the affected epicondyle (discisional tenotomy) (= OP according to Hohmann). In addition, the radial nerve plexus, which rests directly on the radial epicondyle, is severed. For this purpose, the bone surface is simply desolated (Wilhelm's method). This can also be done arthroscopically.

In the far more common case, there is an injury or even a tear in the tendon attachments. Then these tendons should be stably refixed by attaching them directly to the bone. In these cases, healing takes about 6 weeks, during which time the tendon seam is protected by a movement splint.

In the area of ​​the epicondyle ulnaris humeri (golfer's elbow), it is necessary to locate the sulcus and the ulnar nerve and visualize it precisely. As on the radial side, a tendon lengthening ( tenotomy ) of the forearm flexor tendon attachments is performed. With simultaneous ulnar entrapment, the nerve must be freed (decompression) and, if necessary, relocated (transposition).

After the operation, a stabilizing bandage is applied, the arm does not need to be immobilized. In the case of sulcus-ulnaris transposition, a splint can be put on for a short time to immobilize it. Healing usually occurs after about five weeks. Competitive sport is possible again after about three months.

For chronic illnesses lasting more than four months, there is also an alternative therapy using botulinum toxin . The neurotoxin botulinum toxin is injected into the hand and finger extensors (epicondylitis humeroradialis) or hand and finger flexors (epicondylitis humeroulnaris) in one or two places. After the onset of action, the toxin weakens the muscles for about three months after about two to three weeks, so that the tension at the insertion site is reduced and healing can begin. When the effect wears off, the symptoms have usually lessened or even disappeared completely. As a side effect, a clinically noticeable temporary muscular weakness can occur. B. the third finger of the respective hand temporarily hang down a little because of the paralyzing effect when you stretch your hand.

See also

literature

Guidelines

Others

Web links

Individual evidence

  1. Jump up ↑ GF Hatch, MM Pink, K. J. Mohr, P. M. Sethi, F. W. Jobe: The Effect of Tennis Racket Grip Size on Forearm Muscle Firing Patterns. In: The American Journal of Sports Medicine. 34, 2006, pp. 1977-1983, doi: 10.1177 / 0363546506290185 .
  2. ↑ JC Le Huec, T. Schaeverbeke, D. Chauveaux, J. Rivel, J. Dehais: Epicondylitis after treatment with fluoroquinolone antibiotics . In: The Journal of Bone and Joint Surgery. British Volume . tape 77 , no. 2 , March 1995, ISSN  0301-620X , p. 293-295 , PMID 7706350 .
  3. ↑ Barbaros Baykal, HL Yamanel, B Cömert: A case of epicondylitis due to ciprofloxacin therapy . In: Turkiye Klinikleri Journal of Medical Sciences . tape 25 , January 1, 2005, p. 316-318 ( researchgate.net [accessed March 12, 2018]).
  4. ↑ Ludwig Heilmeyer , Wolfgang Müller: The rheumatic diseases. In: Ludwig Heilmeyer (ed.): Textbook of internal medicine. Springer-Verlag, Berlin / Göttingen / Heidelberg 1955; 2nd edition ibid. 1961, pp. 309-351, here: pp. 345 f. ( Local manifestations of soft tissue rheumatism ).
  5. ↑ a b Patrick Vavken: If a tennis elbow is not a tennis elbow ... differential diagnoses of lateral elbow pain . In: Practice . tape 106 , no. 1 , January 2017, p. 29-36 , doi : 10.1024 / 1661-8157 / a002572 , PMID 28055316 .
  6. ↑ Patrick Vavken: But not a simple radius head fracture ... In: Praxis . tape 106 , no. 6 , March 1, 2017, p. 319-321 , doi : 10.1024 / 1661-8157 / a002625 .
  7. ↑ MI Boyer, H. Hastings: Lateral tennis elbow: "Is there any science out there?" In: Journal of Shoulder and Elbow Surgery . Volume 8, Number 5, 1999 Sep-Oct, pp. 481-491. PMID 10543604 . (Review).
  8. ↑ Pia Nilsson, Eivor Thom, Amir Baigi, Bertil Marklund, Jörgen Månsson: A prospective pilot study of a multidisciplinary home training program for lateral epicondylitis. In: Musculoskeletal Care. 5, 2007, pp. 36-50, doi: 10.1002 / msc.97 .
  9. ↑ L. Bisset, E. Beller, G. Jull, P. Brooks, R. Darnell, B. Vicenzino: Mobilization with movement and exercise, corticosteroid injection, or wait and see for tennis elbow: randomized trial. In: BMJ. Volume 333, number 7575, November 2006, p. 939, doi: 10.1136 / bmj.38961.584653.AE , PMID 17012266 , PMC 1633771 (free full text). Quoted from: Success for physiotherapy for tennis elbow In: Ärzte Zeitung , November 21, 2006.
  10. ↑ C. Ries, S. Franke u. a .: The transosseous refixation of the extensors in chronic radial epicondylopathy with and without reconstruction of the LUCL complex - a retrospective analysis of 101 patients. In: Journal of Orthopedics and Trauma Surgery. 151, 2013, p. 296, doi: 10.1055 / s-0032-1328578 .
  11. ^ AB Imhoff and R. Baumgartner: Checklist Orthopädie , Thieme, 2006, ISBN 3-13-142281-5 .