Gefährdung bei Handball, Baseball oder Tennis; Ursachen oft chronische Überanstrengung oder Fehlbelastungen
Beschwerden im Bereich der Schulter und des Ellenbogengelenks finden sich insbesondere bei Überkopfsportlern (Wurfsportarten wie Baseball oder Handball, Rückschlagsportarten etc.) nicht selten. Hierbei handelt es sich weniger um Folgen akuter Traumata durch Sturz oder Gegnereinwirkung, sondern wesentlich häufiger um Auswirkungen wiederholter Mikrotraumata auf Kapseln, Bänder oder Sehnen durch extreme Ausholbewegungen bzw. Beschleunigungs-vorgänge. So werden zum Beispiel im Profitennis Aufschläge mit Geschwindigkeiten bis zu 230 Stundenkilometern gemessen. Beim Handball wird der etwa 450 Gramm schwere Ball von jedem Profispieler im Durchschnitt 48.000 mal pro Jahr auf 110 km/h beschleunigt. Hier werden Spitzenwerte von 130 km/h beschrieben.
Beim Ausholen zum Wurf oder Schlag werden durch die wiederholten und forcierten Schulter-Arm-Bewegungen in Abspreizung/Außendrehung – teilweise passiv verstärkt durch Gegnerkontakt(z. B. beim Griff in den Arm des Handballers während der Wurfphase) – besonders die vordere Kapsel mit den bandförmigen Stabilisatoren (Ligg. Gleno-humeralia) und das Labrum glenoidale belastet.
Als Folge dieser chronischen Überlastungen tritt im Laufe der Zeit eine geringfügig ausgeprägte Schultergelenksinstabilität auf, die den Sportlern im Gegensatz zu den kompletten Luxationen in der Regel nicht bewußt ist. Diese primäre Instabilität führt jedoch häufig durch den nicht mehr in der Gelenkpfanne zentrierten Oberarmkopf zu einem funktionellen Engesyndrom der Rotatorenmanschette unter dem Schulterdach (sekundäres Subacromialsyndrom) oder zu einer vermehrten Belastung des hinteren und oberen Labrums (postero-superiores Impingement, SLAP-Läsion).
Sowohl für die konservative als auch die operative Behandlung des chronischen Schulterschmerzes beim Ballsportler ist somit wichtig, daß der auslösende Faktor der Problematik – nämlich die Instabilität – therapeutisch angegangen wird und nicht die sekundären Folgen, z. B. das subacromiale Impingement. Für die konservative Behandlung sollte somit die muskuläre Stabilisierung und Koordinationsverbesserung durch propriozeptive Schulung im Vordergrund stehen, während bei der operativen Therapie primär die Rekonstruktion des kapsulo-labralen Komplexes und die Normalisierung des Kapselvolumens angestrebt werden sollte.
Bei den Fehlbelastungsfolgen am Ellenbogen stehen die Epicondylopathia humeri radialis (sog. Tennisellenbogen) bzw. die Epicondylopathia humeri ulnaris (sog. Werferellenbogen) im Vordergrund. Der Begriff Epicondylopathie umfaßt akute und chronische Reizerscheinungen an den jeweiligen Epicondylen ansetzenden Muskelursprünge. Die Entstehung basiert auf einem Mißverhältnis zwischen Belastung und Belastbarkeit des Sehnenursprungs der am Epicondylus ansetzenden Muskeln. Besonders bei Rückhandschlägen im Tennis oder Squash kommt es durch den Aufprall des Balles bei exzentrischer Dehnung der angespannten Muskulatur zu Impuls-belastungen der Handgelenksstrecker. Mögliche Einflußfaktoren können in falscher Griff- und Schlägerhaltung liegen. Beim “Werferellenbogen” ist der Sehnenansatz der Handgelenksbeuger betroffen. Diese Ansatztendinosen treten am häufigsten beim Baseballpitcher oder Handballspieler (insbesondere Torwart durch weiten Abwurf beim Tempogegenstoß) auf.
Die konservative Behandlung ist mit Erfolgsaussichten von etwa 90 Prozent die Therapie der Wahl. Sie besteht im Akutstadium in lokaler Eisanwendung und Gabe von Antiphlogistika sowie Ruhe bis zum Abklingen der Symptome. Gegebenenfalls kommen lokale Kortisoninfiltrationen in Frage, wobei jedoch nicht mehr als zwei bis drei Injektionen erfolgen sollten. Um den Behandlungserfolg nicht zu gefährden, sollte mit höherer Trainingsbelastung erst dann begonnen werden, wenn Beschwerdefreiheit besteht und volle Kraft sowie Flexibilität wiederhergestellt sind. Die Gesamtdauer der Rehabilitation beträgt etwa vier Monate. Eine operative Therapie ist bei Ausschöpfung der konservativen Möglichkeiten und entsprechender Geduld nur selten notwendig. Die verbreitetste Operationstechnik ist die Sehneneinkerbung nach Hohmann, die in Kombination mit der Denervation nach Wilhelm durchgeführt wird. Seltener erfolgt die lokale Exzision von pathologischem angiofibroblastischem Sehnengewebe – meistens im extensor carpi radialis brevis – nach Nirschl. Die Rehabilitationsphase nach operativer Behandlung umfaßt bis zu einem halben Jahr.
In seltenen Fällen können bei ungewohnten bzw. übermäßigen Beanspruchungen knöcherne Streßreaktionen auftreten – auch unter den Begriffen Streß- oder Ermüdungsfraktur bekannt. Auf den Ellenbogen- und Unterarmbereich bezogen werden in der Literatur Streßreaktionen des Olecranons bei Baseball-Pitchern und Speerwerfern sowie Streßreaktionen am distalen Radius bzw. der distalen Ulna bei Tennisspielern erwähnt. Das Röntgenbild zeigt häufig zum Zeitpunkt der Diagnose keine sicheren knöchernen Veränderungen, während die Knochenszintigraphie die Diagnose sichert.
Die Therapie erfolgt konservativ durch Vermeidung der sportartspezifischen lokalen Belastung für sechs bis acht Wochen und anschließender langsamer Belastungssteigerung. In Ausnahmefällen kann eine Ruhigstellung erfolgen.
17. Juli 2002
Dr. med. Hans-Gerd Pieper
Klinik für Orthopädie und Orthopädische Chirurgie mit Sportmedizin
Alfried Krupp Krankenhaus
Alfried-Krupp-Str. 21
45117 Essen
Tel. 0201-434-2540
FAX 0201-434-2572
e-mail: hans-gerd.pieper@krupp-krankenhaus.de
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