Tennis
Elbow }

Pathology

Tennis elbow is a tendinopathy of the common extensor origin of the lateral elbow. In former times the condition was usually named "lateral epicondylitis". However, the pathology is no longer thought to be inflammatory. Nowadays the accurate description would be "partially reversible but degenerative overuse-underuse tendinopathy". Because of the complexity of this description, the term "tennis elbow" is usually used.

The main clinical symptoms are pain on resisted movements (particularly resisted third finger extension) and tenderness at the lateral epicondyle, with normal elbow range of motion. Diagnosis is based on the clinical features of the disease. Diagnostic imaging should be considered to rule out other causes of elbow pain or to establish the diagnosis of tennis elbow when in doubt.

As with other tendinopathies the pathology of tennis elbow is complex and not fully understood. Similar to calcifying tendinitis of the shoulder, sudden overload may alter the structure of the tendons at the common extensor origin, leading to a degenerative process. However, calcifications are rare in tennis elbow. Involvement of neurogenic inflammation in tennis elbow has also been suggested.

The population prevalence is approximately 2%, with peak incidence occurring at 40 to 50 years of age. Approximately 40% of all tennis players report problems with their elbow, but only a quarter of them consider the symptoms to be disabling and severe. Notably most patients with tennis elbow do not play tennis. This is due to the fact that many tennis players have a weekly training routine that regularly loads the tendons and keeps them healthy. Rather, the injury usually occurs in people who have been sedentary for years and then overuse a previously underused and atrophied tendon by exercising at the gym, doing gardening, or even just carry heavy luggage. When the injury is caused by playing tennis it is the backhand stroke that leads to excessive loading of the tendons at the common extensor origin.

The initial treatment should be conservative including rest, physiotherapy, and nonsteroidal anti-inflammatory drugs. As in the case of chronic Achilles tendinopathy and chronic plantar fasciopathy, eccentric (lengthening only) exercises have become the mainstay of rehabilitation programs for tennis elbow. An attractive alternative is Radial Shock Wave therapy (RSWT). In most circumstances, cortisone injections should not be used. This is due to the fact that cortisone leads to very good results in the short term (six weeks) but has been demonstrated to be harmful in the longer term (more than three months). Surgery should be considered when conservative treatment fails.

 

Treatment Procedure

1. PALPATE
Locate the area of pain through palpation and biofeedback.

2. MARK
Mark the area of pain.

3. APPLY GEL
Apply coupling gel to transmit shock waves to the tissue.

4. APPLY SHOCK WAVES
Deliver Radial or Focused Shock Waves to the area of pain while keeping the applicator firmly in place on the skin.

 

Recommended Settings

Swiss
DolorClast }

  Treatment Myofascial therapy
Number of treatment sessions 3 to 5 3 to 5
Interval between two sessions 1 week 1 week
Air pressure Evo Blue® 1.5 to 3 bar 3 to 4 bar
Air pressure Power+ Not recommended Not recommended
Impulses 2000 on the painful spot 2000
Frequency 8Hz to 12Hz 12Hz to 20Hz
Applicator 15mm 36mm
Skin pressure Light Light to moderate

 

Clinical Proofs

Spacca G, Necozione S, Cacchio A.
Radial shock Wave therapy for lateral epicondylitis. A prospective randomised controlled single-blind study. Eura Medicorphys 2005; 41:17-25
http://www.ncbi.nlm.nih.gov/pubmed/16175767

Söller F.
Die radiale Stosswellentherapie bei der Epikondylitis humeri radialis – kurz- und mittelfristige Ergebniss. In: Maier M, Gillesberger F: Abstracts 2003 zur Muskuloskelettalen Stosswellentherapie. Norderstedt 2003; 121-122
http://www.abebooks.co.uk/9783833004230/Abstracts-2003-Muskuloskelettalen-Stosswellentherapie-Gillesberger-3833004231/plp

Krischnek O, Hopf C, Nate b, et al.
Shock-wave therapy for tennis and golfers’s elbow – 1 year follow up. Arch Orthop Trauma Surg 1999; 62-66
http://www.ncbi.nlm.nih.gov/pubmed/10076947

Risks

Side effects of Radial Shock Wave Therapy (RSWT) using the Swiss DolorClast®.

When performed properly, RSWT with the Swiss DolorClast® has only minimal risks.
Typical device-related nonserious adverse events are:

  • Pain and discomfort during and after treatment (anesthesia is not necessary)
  • Reddening of the skin
  • Petechia
  • Swelling and numbness of the skin over the treatment area


These device-related nonserious adverse events usually disappear
within 36h after the treatment.

Accordingly the following contraindications of RSWT using the Swiss DolorClast® must be considered:

  • Treatment over air-filled tissue (lung, gut)
  • Treatment of pre-ruptured tendons
  • Treatment of pregnant women
  • Treatment of patients under the age of 18 years (except for Osgood-Schlatter disease and muscular dysfunction in children with spastic movement disorders)
  • Treatment of patients with blood-clotting disorders (including local thrombosis)
  • Treatment of patients treated with oral anticoagulants
  • Treatment of tissue with local tumors or local bacterial and/or viral infections
  • Treatment of patients treated with cortisone

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