Golfers Elbow

What is it?

The medial epicondyle is the attachment for the flexor-pronator group of muscles. Repetitive flexion and pronation can create a strain on the common flexor origin and result in irritation. Recurring valgus stress is thought to be another trigger of medial epicondyle pain.

Injuries to the common flexor origin may occur abruptly as a result of trauma, excessive stretch, or eccentric overload, but the majority of medial elbow problems can be blamed on chronic, degenerative pathologies rather than acute injuries. Tendinpathies begin from repetitive overloading and micro-tearing, and culminate with a disorganized healing process that fails to regenerate a “normal” tendon.

This condition is commonly called “golfer’s elbow” but it affects those participating in sports that require a repetitive flexion and pronation or exposure to valgus stress, such as golf and throwing. Golfers are at risk when they are coming from the top of their back swing until ball impact. Similarly, in baseball, the medial elbow is at highest risk during the acceleration phase of throwing. Other triggers are sports such as bowling, javelin, throwing, football, archery, and weight lifting. Occupations that require flexion and pronation, like carpentry, are at risk for this condition.

Several factors may increase an athlete’s risk to injury, including inadequate warm up, poor conditioning, weakness, inflexibility, and improper technique.

Some other factors that predispose someone for medial epicondylopathy is smoking and type 2 diabetes. Obesity nearly doubles the risk of developing medial epicondylopathy as well.

Clinical Presentation

Symptoms include a slow onset of “dull aching” pain over the medial side of the elbow that becomes more acute with use. Those with a high level of irritation may experience a weakness in their grip strength that will cause an issue with things like shaking someone’s hand, grabbing objects, and opening jars.

Patients may notice some swelling on the medial side of the elbow.

Reproduction of pain with resisted forearm pronation is the most common finding for a clinician that it is medial epicondylopathy. Resisted wrist flexion will likely cause discomfort. In chronic cases, resisted elbow flexion may induce symptoms.

Throwing athletes with chronic medial epicondylopathy may develop a flexion contracture that limits elbow extension.

Diagnosis

Plain film radiography is often unnecessary for the diagnosis of medial epicondylopathy. Radiographs are usually reserved for patients who are not responding to conservative care after a few months or if there was some type of trauma to the elbow. About twenty to thirty percent of patients with medial elbow complaints will demonstrate radiographic evidence of calcification adjacent to the medial epicondyle consistent with calcific tendinitis.

Management

Medial epicondylopathy can prove to be a challenging condition. Between 5 and 26 percent of patients experience recurrent episodes, and 40 percent suffer from prolonged discomfort. Almost 25 percent of unmanaged patients will continue to experience symptoms for over one year. Nearly 19 percent of patients continue to experience symptoms after three years.

Conservative, non-surgical management is the most appropriate treatment for medial epicondylopathy.

Selective rest, ice, and NSAIDs (nonsteroidal anti-inflammatory drugs) may help alleviate acute inflammation, but do little to alter the long-term course of chronic tendinopathy. Applying ice or an ice massage may help with acute pain as well. A more comprehensive management approach for chronic complaints adds bracing, eccentric rehabilitation, and activity modification.

Clinicians should consider the use of counterforce brace to restrict flexion and pronation forces on the medial side of the elbow. “Cock-up” wrist splints may be useful at night to allow the tendon to heal in a neutral or lengthened position.

Soft tissue manipulation, stretching, and myofascial release techniques are necessary to promote flexibility of the forearm and wrist. Maintaining range of motion and addressing flexion contractures, especially with throwing athletes, is important. Clinicians should consider the use of IASTM (instrument assisted soft tissue mobilization) to release adhesions within the common flexor tendon.

The benefit of cervical spine manipulation has been established for patients with elbow pain. Clinicians should address restrictions at the elbow, wrist, and shoulder as well.

Soft tissue manipulation, stretching, and myofascial release techniques are necessary to promote flexibility of the forearm and wrist. Maintaining range of motion and addressing flexion contractures, especially with throwing athletes, is important.

When it comes to tendinopathies, eccentric exercises are important, therefore with medial epicondylopathy the patient should eccentrically strengthen the wrist flexors and forearm pronators.

In addition, it has shown proven benefit of dry needling in reluctant cases of medial epicondylopathy.

NSAIDs may provide some temporary analgesic benefit, but since tendinopathy is not a true inflammatory condition, their usefulness is very limited to the acute phase. Likewise, corticosteroid injections have demonstrated short-term improvement with little long-term effect.

Surgical intervention should be considered for cases that are unresponsive after three to six months of care.