An Overview of Golfer's Elbow

Golfer's elbow, known more precisely as medial epicondylitis, is an injury to the tendons attached to the medial epicondyle. It is considered an overuse injury in which repetitive force places stress on connective tissues, causing pain, inflammation, and a reduced range of motion.

Golfer's elbow is similar to tennis elbow but differs in that it involves a different movement and the medial (inside) rather than lateral (outside) epicondyle.

Golfer's elbow can be diagnosed with a physical exam and imaging tests if needed. Treatment typically involves rest, ice application, splinting, and oral analgesics to reduce pain. Steroid injections and surgery are reserved for only the most serious cases.

Symptoms

Pain on the inside of the elbow during or after intense use is the defining feature of medial epicondylitis. Unlike tennis elbow, the pain will increase with wrist flexion (when the wrist is bent inward) and often radiates to the forearm.

There may also be elbow weakness when grasping or carrying objects, particularly when the wrist is pronated (with the palm facing downward). For some, the pain may be chronic and debilitating.

Causes

Despite its name, golfer's elbow is more commonly linked to an occupational injury rather than sports. It is related to the way in which the elbow moves in relation to the wrist and the force placed on the elbow when the wrist is flexed.

Using golf as an example, medial epicondylitis is often attributed to the impact placed on the elbow whenever a golfer accidentally hits the ground on the downward swing (making a "divot"). Any forceful movement that requires a firm grip and a flexed wrist can do the same.

Anatomically speaking, the wrist flexor muscles are located on the palm side of the forearm and is attached via the common flexor tendon to the medial epicondyle. The combination of a tight grip with a flexed wrist can place undue stress on the inner elbow if the opposing force is great enough. Over time, this can lead to tiny tears in the tendon and the development of tendinitis or tendinopathy.

Tendinitis and tendinopathy are two different forms of tendon injury. Although the terms are often used interchangeably, tendinitis infers an acute injury, while tendinopathy is assigned to repetitive use injuries in which degeneration of the tendon is involved.

Within this context, tendinitis suggests a shorter course of treatment, while tendinopathy describes a chronic or recurrent condition that requires longer-term or ongoing care.

Diagnosis

Golfer's elbow can usually be diagnosed with a physical exam and a review of symptoms and medical history (including the type of work you do).

During the physical exam, the doctor will typically apply force to the elbow and wrist. If you experience pain or are unable to resist the force on the medial side, golfer's elbow will be one of the more likely culprits.

Imaging tests may be ordered to check for tears or inflammation in the medial epicondyle or to rule out other causes (such as a fracture). This may involve an ultrasound, X-ray, or magnetic resonance imaging (the latter of which is better able to image soft tissues).

Differential Diagnoses

If the cause of elbow pain is uncertain, the doctor may explore other possible causes in the differential diagnosis, including:

• Ulnar nerve disorders (typically caused by compression of the ulnar nerve in the elbow)
• Cervical radiculopathy (caused by referred pain from cervical spine compression)
• Ulnar collateral ligament injury (typically a ligament tear on the medial side of the elbow)
• Rupture of the distal tricep (involving the lower end of the tricep muscle of the upper arm)

Treatment

Golfer's elbow is usually treated conservatively. The first step would be to stop the activity causing the pain, followed by the RICE protocol (rest, ice application, compression, and elevation of the joint). This will help decrease the inflammation and provide temporary pain relief.

If the pain is severe, an elbow splint may be used to stabilize the joint and provide compression. An over-the-counter nonsteroidal anti-inflammatory drug (NSAID) like Advil (ibuprofen) or Aleve (naproxen) may also be prescribed.

On rare occasions, if the pain is severe enough, the doctor may recommend an intra-articular cortisone injection (delivered into the joint space) to quickly reduce inflammation and pain.

Physical Therapy

Whatever the severity of your condition, physical therapy exercises are strongly encouraged to regain strength and restore the range of motion to the joint. This may involve:

• Isometric Wrist Extension Exercises: Bend the wrist backward while applying pressure in the opposite direction with your other hand.
• Isometric Wrist Flexion Exercises: Bend the wrist forward while applying pressure in the opposite direction with your other hand.
• Resistant Wrist Extension: Rest your forearm on a table and move the wrist from a neutral position to an upward position and back while holding a lightweight.
• Resistance Wrist Flexion: Rest your forearm on a table and move the wrist from a neutral position to a downward position and back while holding a lightweight.
• Straight-Armed Wrist Stretch: Extend your arm with your palm turned upward and pull the fingers and wrist toward the body with your other hand.

Ultrasound therapy is also sometimes used to treat chronic elbow pain. While it is believed that the high-frequency sound waves can speed healing by warming tissues and increasing circulation, the evidence of its effectiveness remains uncertain at best.

Surgery

Surgery is rarely performed with golfer's elbow but may be considered if the symptoms persist for longer than six months and are interfering with your quality of life.

In such cases, a minimally invasive procedure called a percutaneous elbow release may be performed. For this operation, the flexor tendon (which attaches the medial epicondyle to the upper arm bone) would be detached and the elbow space cleaned of debris. It can usually be performed as an arthroscopic ("keyhole") surgery under local anesthesia.

When to See a Doctor

If you experience pain in the inner elbow that worsens when the wrist is flexed, you can try treating it with the RICE protocol to see if the symptoms improve. If they don't or get worse, you should make every effort to see a doctor or sports medicine specialist. In some cases, you may suspect golfer's elbow but find that some other, potentially serious condition is to blame.

This is especially true if the elbow pain is chronic or recurrent. The problem with golfer's elbow is that it tends to be progressive. Unless you find ways to correct the mechanics that contribute to golfer's elbow, a case of tendinitis can easily progress to tendinopathy.

In some cases, the doctor or physical therapist will recommend that you wear an elbow brace on an ongoing basis to reduce stress during work or physical activity. Ongoing wrist strengthening exercises can also reduce the risk of reinjury.