Golfer’s elbow is also known as medial epicondylitis and is the less common sister condition of tennis elbow, both conditions sharing the tendon degenerative nature without inflammation. They are referred to as tendinopathies due to the pathological changes which occur inside the tendon without an inflammatory process. Not just occurring in golfers, golfer’s elbow also appears in racquet sports, cricket bowling, weightlifting and archery.
The muscles which flex and rotate the forearm originate over the medial epicondyle, the bony prominence on the inside of the elbow, with the tendon anchored into the bone by the tendinous insertion. The pain occurs close to this and may be due to a degenerative process occurring in the tendon, as little inflammation has been noted in these cases.
The flexor tendons are put under stress by activities which force the forearm outwards away from the body and these stresses occur as the wrist is cocked prior to throwing, in the early acceleration of the throw and in the golf swing from high backswing to just before the ball is hit. The dominant hand is affected in golfers and in tennis players those who impart a heavy topspin to the ball are more likely to suffer.
Golfer’s elbow is not as common as tennis elbow but is the commonest cause of medial elbow pain with about half as many women affected as men. The third to fifth decades of life are the commonest periods for pain onset and 60% of golfer’s elbow occurs in the dominant hand. An acute onset of pain is reported in a third of patients, with the other two-thirds developing over a period of time.
Pain and ache over the front of the medial epicondyle is the typical symptom, worse with repeated flexion of the wrist and improved with resting. Shoulder, elbow, forearm or hand pain can occur, with weakness or pins and needles in the lower arm. Physiotherapy examination includes the bony tendon insertions, the elbow joints and the muscles, with palpation of the “funny bone” area behind the elbow where the ulnar nerve lies. Nerve involvement can give weakness in the forearm muscles and sensory symptoms, so an exclusion neurological examination is performed by the physio.
Most golfer’s elbow treatment is conservative, not surgical. Treatment involves activity modification, forearm or wrist splinting, anti-inflammatory drugs, steroid injections and physiotherapy. Modification of the use of the arm is vital to prevent ongoing stimulation of the condition, so altering the mechanics of swinging the golf club or other sporting equipment is essential. Patient education continues with the identification of aggravating activities and postures and the patient is taught to avoid them.
Cryotherapy (cold therapy), gentle stretching, ultrasound, frictions and anti-inflammatory drugs are the main treatments for acute golfer’s elbow. Once it has settled down into the sub acute condition then the aim is to increase flexibility by stretches, improve the strength of the muscles and go back to normal daily jobs. Bracing can be used either to rest the musculature (wrist brace) or to realign the forces through the tendons (counterforce bracing). In the case of chronic golfer’s elbow the treatment can be the above plus gradual weaning out of the splint and paced return to sport.
Scientific work shows that steroid injections can be useful in the early stages of golfer’s elbow to reduce pain and the time to recovery, but they are also used in chronic situations. There is no evidence that shockwave or laser therapy has any effectiveness and surgery is contemplated when a significant period of physiotherapy has been attempted without success. The surgeon removes the abnormal tendinous tissue and if the ulnar nerve is involved he may move it around to the front of the elbow from its posterior groove.
Correction of sporting technique, such as the golf swing, is best achieved by engaging a professional instructor who can also advise on stretches, fitness work and muscle strengthening. Athletes should warm up well before sport and stretch effectively afterwards, choosing good technique and selection of appropriate equipment. Doctors and physiotherapists may need to monitor patients, especially athletes, very carefully as they tend to continue to perform through the pain.
