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Musculoskeletal disorders of the elbow

The elbow pain may originate from the joint itself, attached bone or tissue to the joint, such as tendons. This sheet focuses on the 2 most common types of elbow tendon injuries . They are commonly referred to as the tennis elbow and the elbow of golfer ‘s elbow , but they do not affect only these athletes. Usually, it is the fact of soliciting the wrist repeatedly or with unusual intensity that can become harmful.

These injuries most often affect people in their forties or fifties, and as many women as men.

Types of Musculoskeletal disorders of the elbow

“Tennis player’s elbow” or external epicondylalgia (formerly called epicondylitis)
It affects 1% to 3% of the population. However, tennis is not the main cause of an external epicondylalgia. Moreover, the players are now rarely reached since the majority of them perform their backhand with both hands and use rackets much lighter than before.

The pain is mostly localized in the outer part of the forearm, in the epicondylic region (see diagram above). The epicondyle , also called external epicondyle, is a small bony protrusion of the outer face of the humerus, located near the elbow.

The elbow of the tennis player is the consequence of overwork of the extensor muscles of the wrist. These muscles can bend the wrist upward and straighten the fingers.

“Golfer’s Elbow” or Internal Epicondylalgia (formerly called Epitrochleitis)
This condition is 7 to 10 times less common than tennis player’s elbow. It affects golfers, but also people who practice racket sport, baseball throwers and manual workers. The pain is located in the inner part of the forearm, in the region of the epitrochlea (see diagram above). The epitrochlea , also called internal epicondyle, is a small bony prominence of the medial aspect of the humerus.

The golfer’s elbow is the result of overworking the flexor muscles of the wrist. These muscles can bend the wrist and fingers down.

For more information, see our article entitled Anatomy of the joints: basic concepts .

Causes of Musculoskeletal disorders of the elbow

When the same gestures are often repeated or improperly forced, small injuries appear in the tendons. These micro-traumas cause a decrease in tendon elasticity because the collagen fibers produced to repair the tendons are not as good as the original tendon.

Elbow “wear” or irritation of the nerves adjacent to the elbow may also cause pain and inflammation . Although these lesions do not systematically induce inflammation of the tendons, the surrounding tissues can ignite and damage the elbow joint.

Evolution

The pain usually persists for a few weeks, sometimes several months. It is rare that it lasts more than 1 year (less than 1% of cases).

Possible complications

Unnoticed or unhealthy epicondylalgia leaves lesions that can lead to chronic pain, which is much more difficult to heal.

Symptoms of Musculoskeletal disorders of the elbow

  •  A pain radiating from the elbow to the forearm and wrist. The pain gets worse when you grab an object or shake someone’s hand. The pain sometimes radiates when the arm is still.
  • Touch sensitivity in the outer or inner region of the elbow.
  • Rarely, there is a slight swelling of the elbow.

People at risk

Tennis player’s elbow (external epicondylalgia)

  • Carpenters, masons, jackhammer operators, assembly line workers, people who often use a computer keyboard and a mouse arranged in an ergonomic manner, etc.
  • Tennis players and people who practice other racket sports.
  • Musicians playing a string instrument or drums.
  • People over 30 years old.

Golfer’s elbow (internal epicondylalgia)

  • Golf players, especially those who often hit the ground before the ball.
  • People who practice a racket sport. In tennis, players often use a forehand topspin or brushed ( topspin ) are most at risk.
  • Athletes whose throws require a movement of whip wrist, such as baseball pitchers, throwers, javelin throwers …
  • Bowlers.
  • Workers who frequently lift heavy objects (transport of suitcases, heavy boxes, etc.).

Risk factors for Musculoskeletal disorders of the elbow

At work or when doing maintenance or renovations

  • An excessive rate that prevents the body from recovering.
  • Extended shifts. When fatigue is gaining the shoulders, the reflex is to compensate by the wrist and the extensor muscle of the forearm.
  • Hand and wrist movements that require great strength.
  • The use of an inappropriate tool or the misuse of a tool.
  • A poorly designed workstation or incorrect working positions (such as fixed positions or computer workstations without ergonomic considerations).
  • The use of a tool that vibrates (trimmer, chain saw, etc.), using the wrist inappropriately or too intense.

In the exercise of a sport

  • Musculature insufficiently developed for the effort required.
  • A bad game technique.
  • The use of equipment that does not match the size and level of play.
  • Activity too intense or too frequent.

 

 

Basic preventive measures

General recommendations

  • Keep fit by doing exercises that stimulate heart and breathing rhythms (walking, running, cycling, swimming, etc.).
  • Strengthening the extensor and flexor muscles of the wrist is a vital part of prevention. Consult a physiotherapist, a kinesiologist, a physical educator or a sports therapist.
  • Do warm – up exercises all over the body before sport or work.
  • Take frequent breaks .

Prevention at work

  • Choose tools adapted to the anatomy. Pay particular attention to the dimensions of the tool handle.
  • Operating a job rotation work.
  • Use the services of an ergonomist or occupational therapist to implement a prevention program. In Quebec, experts from the Commission for Occupational Health and Safety (CSST) can guide employees and employers in this process (see Sites of Interest).

Ergonomics tips for working at the computer

  • Avoid having your wrists broken (bent up) when working with the keyboard and with the mouse. Various models of ergonomic armrests are commercially available . Note that the wrist rests should be avoided, as they very often lead to an extension of the wrist.
  • Rely on the back of the chair, with your back straight , to prevent the reflex from putting weight on your wrists.
  • Moderately use the scroll wheel of the mice that have them. Its repetitive use requires increased effort to the extensor muscles of the forearm.
  • If the mouse has 2 main buttons, configure it so that the most used button is the right button (for the right-handed ones) and use the index to click. The hand is thus in a more natural position.

Prevention among athletes

The idea is to use the services of a competent sports coach to learn safe and effective techniques. He can also teach various exercises to stretch and strengthen the tendons. Here are some prevention tips.

For racket sports

  • Choose a racket that corresponds to its size (racket weight, handle size, etc.) and its level of play. Consult a professional.
  • An athlete who wants to increase the pace of his training should do so gradually.
  • Properly adjust the tension in the racket’s string: a string that is too tight increases stress on the forearm.
  • Be sure to develop and maintain good muscle strength in the trunk. In some tennis players, the muscles of the upper back are weak and do not offer enough power in the shoulder. To compensate for this weakness, these players use more often shots that give an effect to the ball (cut or brushed shots, slice or topspin ), attributable to the movements of the wrist.
  • Adopt a good position to hit the ball. A “late” strike creates extra stress in the elbow, such as beating the ball while the elbow is bent toward you. This can be the result of a bad game of feet or a bad anticipation of the game.
  • The ball should touch the racket as much as possible in the center to reduce vibrations, which are absorbed by the wrist and elbow.
  • Avoid playing with wet tennis balls.
  • Play against an opponent whose level of play is similar to ours.
  • When returning to play after an injury, put a rigid epicondylar band 1 or 2 inches below the elbow. This can help reduce tension on sore tendons, but does not replace treatments.

Golf

  • Learning a good game technique is the best way to prevent epicondylalgia in golfers. Often, it is the end of the acceleration movement (which just precedes the impact of the stick on the golf ball) that must be corrected, because the stress on the elbow is powerful at that time. Consult a sports trainer.

Medical treatment of musculoskeletal disorders of the elbow

It is important to consult a doctor in case of  elbow pain . Tendons can suffer irreversible damage if they continue to be used, despite the use of medication.

Acute phase

The duration of the acute phase of the injury varies. It is about 7 to 10 days . During the first 48 to 72 hours, it is important to immediately relieve the pain and inflammation that may be present. The injury is fragile and the tissues are more easily irritable than usual.

Here are a few tips :

  • Put the elbow at rest by avoiding the actions that led to the injury. However, it is necessary to avoid the complete stop of the movements. Indeed, if rest is an essential component of treatment, prolonged inactivity can stiffen the joints (ankylosis). Thus, you should never immobilize your arm with a sling or splint.
  • Apply ice on the elbow 3 to 4 times a day for 10 to 12 minutes. There is no need to apply cold compresses or magic bags (they are not cold enough and heat up in minutes). Continue applying ice as long as symptoms persist.
Tips and warnings for applying cold

Ice cubes can be applied directly to the skin in a plastic bag or in a thin, wet towel . There are also ice pak gel packs available in pharmacies, which may be practical. However, when using these products, do not place them directly on the skin because there is a risk of frostbite. A bag of frozen green peas (or corn kernels) is a practical and economical solution, as it molds well to body shapes and can be applied directly to the skin.
In the case of epicondylalgia, as the wound is located very close to the skin, the following method can also be used: freeze water in astyrofoam glass filled to the brim; remove the styrofoam border at the top of the glass to reveal the ice on 1 cm thick; massage the affected area with the surface of the cleared ice.

Drugs . During this phase, the doctor may suggest taking an analgesic (Tylenol or others) or a nonsteroidal anti-inflammatory drug, such as aspirin or ibuprofen, available over-the-counter (Advil, Motrin or others), naproxen (Naprosyn) or diclofenac (Voltaren) obtained by prescription. Do not take anti-inflammatory drugs more than 2 or 3 days. Analgesics can be taken longer.

Knowing that epicondylalgia is rarely accompanied by inflammation, cortisone injections no longer have a place in treatment.

Rehabilitation phase

Physiotherapy treatments should begin as soon as the diagnosis of epicondylalgia is made. Physical therapy can redirect collagen fibers, prevent ankylosis and recover lost mobility. This can be done by means of massage, friction, ultrasound, electric currents, laser, etc.

Once the pain is reduced, the focus is on muscle building while continuing to work on the mobility of the joint. It is especially important to strengthen the extensor muscles (for the elbow of the tennis player) and the flexor muscles (for the elbow of the golfer) of the wrist. For this type of injury, it has been proven that eccentric reinforcement , that is to say, to force while the muscle is growing longer, is the basis of the treatment.

It may be necessary, in more severe cases, to wear an orthosis (splint) designed to reduce the tension on the epicondylar muscles during wrist movements that are causing the problem. The rigid epicondyle bands, which look like bracelets placed under the elbows, are the most used. However, beware of fabric models (with or without a hard washer) or elastic bands sold in pharmacies, which are ineffective. It is better to buy them in orthopedic appliances stores.

Back to normal activities

The normal activity (the movements that caused the injury) is gradually resumed, when the full range of motion is covered and the pain is controlled. A follow-up in physiotherapy makes it possible to prevent relapses. It is however essential to continue reinforcement exercises .

Surgery

Surgery is performed extremely rare. Generally, it is only used when the usual treatments do not lead to satisfactory results after several months. It should be known that the results are often disappointing.

Important. Incomplete rehabilitation or rapid return to normal activities slows the healing process and increases the risk of recurrence. Compliance with treatment – rest, ice, analgesic medication, physiotherapy, reinforcement exercises – results in a return to previous abilities for the majority of people.

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