Golfer's elbow is a pain on the inside of the elbow, also called medial epicondylopathy, previously called medial epicondylitis. The medial epicondyle is a common origin point for several muscles: pronator teres, flexor carpi radialis, palmaris longus, flexor digitorum superficialis, and flexor carpi ulnaris. (1) These muscles also serve as a secondary stabilizer to the ulnar collateral ligament and medial elbow (2). Repetitive bending and pronation (inward turning/twisting of the forearm)create strain on the common flexor origin resulting in irritation. Recurring valgus stress is thought to be another principal trigger for medial epicondyle pain (1,3,4).
Tendonitis vs. Tendonopathy:
Injuries to the common flexor origin may occur abruptly as a result of a trauma, excessive stretch, or eccentric overload, but the majority of medial elbow problems can be blamed on chronic, degenerative “tendinopathies” rather than any acute inflammatory response called tendonitis (6-8). Tendinopathies begin from repetitive overloading & micro-tearing, and culminate with a disorganized healing process that fails to regenerate a “normal” tendon.
Elbow pain and golfer’s elbow:
Medial epicondylopathy is the most frequent cause of medial elbow pain, but is 3-10 times less common than lateral epicondylopathy. (2,12-15) It is most prevalent in the fourth and fifth decade and affects men and women fairly equally. (6,12) The condition strikes the dominant arm in 75% - 82% of cases. (6,16-18).
But what if I don’t play golf?
Although the condition is named “golfer’s elbow,” one study found that 90- 95% of those affected were not even athletes, much less golfers. (13) Nonetheless, the condition is more common in certain populations, particularly those participating in sports that require repetitive flexion/pronation or exposure to valgus stress, such as golf and throwing (19). Golfers are most vulnerable from the top of their back swing until ball impact (19). Similarly, in baseball players, the medial elbow is at highest risk during the acceleration phase of throwing (19,20). The condition is common in racquet sports, particularly those who hit with heavy topspin (16,21). Bowling, javelin throwing, football, archery, and weight lifting are potential triggers (6,21,22). Occupations that require repetitive flexion and pronation, like carpentry, predispose patients to medial epicondylopathy (6).
What are the risk factors?
Several factors may increase an athlete’s risk to injury, including inadequate warm up, poor conditioning, weakness, inflexibility, and improper technique. (21) An improperly sized racquet grip, excessively tightened racquet strings, and using old or wet tennis balls increase elbow stress. (21) Smoking, obesity, and Type II diabetes are additional known risk factors. (12,55)
What are the symptoms of medial epicondylopathy?
Symptoms include an insidious onset, “dull aching” pain over the medial elbow that becomes more acute with use. (23) Patients with more significant irritation may complain of grip weakness and notice limitations in activities of daily living, like shaking hands, grasping objects, and opening jars. (24) Patients may notice local swelling. (25)
Do I need x-rays or imaging?
Plain film radiography is often unnecessary for the diagnosis of medial epicondylopathy. (21) Radiographs may be required in cases of trauma and in those patients who are unresponsive to a trial of therapy. Radiographs are warranted in adolescents complaining of medial epicondyle pain in order to rule out avulsion fracture. In children and adolescents, the open epiphyseal growth plate is two to five times weaker than in adults where the growth plate is closed. This means that children are more likely to suffer apophyseal injuries (i.e. “Little League Elbow”) from stressors that would likely cause tendinopathies in adults (32). MRI can demonstrate ligamentous injury and osteochondritis dissecans. MRI arthrography may be more appropriate to identify ruptures of the medial collateral ligament. Diagnostic ultrasonography is a useful imaging tool for medial epicondylopathy (33)
Management of golfer’s elbow:
Medial epicondylopathy can prove to be a defiant condition. Between 5 and 26% of patients experience recurrent episodes, and 40% suffer prolonged discomfort. Almost twenty-five percent of unmanaged patients will continue to experience symptoms for over one year (34). Nineteen percent of patients continue to experience symptoms after three years (14,35). Conservative, non-surgical management is the most appropriate treatment for medial epicondylopathy (6).
What are the best treatment options for golfer’s elbow?
- Selective rest, ice, and NSAIDs may help alleviate acute inflammation, but do little to alter the long-term course of chronic tendinopathy. A more comprehensive management approach for chronic complaints adds bracing, eccentric rehabilitation, and activity modification.
- Athletes may need to limit or temporarily discontinue offensive activities. Applying ice or ice massage may help alleviate acute pain.
- Modalities including e-stim, ultrasound, and laser have varying levels of support and may be useful to help control symptoms (56)
- Clinicians should consider the use of a counter-force brace to dampen flexion/pronation forces to the medial epicondyle (21,36) Counter-force braces should not be used in cases of concurrent cubital tunnel syndrome, as the additional pressure will likely exacerbate compressive neuropathy symptoms.
- Cock-up wrist splints may be useful at night to allow the tendon to “heal” in a neutral or lengthened position. (21,37)
- Soft tissue manipulation, stretching, and myofascial release techniques are necessary to promote flexibility of the forearm muscles (6)
- Clinicians should consider the use of IASTM to release adhesions within the common flexor tendon. As an additional benefit, IASTM may facilitate a healing response by inducing controlled microtrauma (38)
- Maintaining range of motion and addressing flexion contractures is particularly important in throwing athletes. Mobilization or oscillatory manipulation may help restore full extension in cases of flexion contracture (39)
- The benefit of cervical spine manipulation has been established for patients with elbow pain (40)
- Clinicians should address restrictions at the elbow, wrist, and shoulder as well.
- Like other tendinopathies, eccentric strengthening of the wrist flexors and forearm pronators is believed to be a critical component of treatment (3,41,57)
- The “Tyler Twist” exercise, utilizing a Theraband Flexbar is a novel approach to eccentric strengthening that has shown significant pain reduction and excellent outcomes in limited trials for lateral epicondylopathy. The “Reverse Tyler Twist” exercise was created for the treatment of medial epicondylopathy. (58,59)
Other Treatment Options:
- NSAIDS may provide some temporary analgesic benefit, but since medial epicondylopathy is not a true inflammatory condition, their usefulness is limited.
- Likewise, corticosteroid injections have demonstrated short-term improvement with little long-term effect. (42,43)
- The benefit of utilizing autologous blood injections, PRP injections and Extracorporeal Shock-Wave Therapy (ESWT) for the treatment of medial epicondylopathy has not been examined closely, but mixed data supports their use for lateral epicondylopathy (44-52,60).
- The addition of dry needling to autologous blood injection has proven benefit in recalcitrant cases of medial epicondylopathy (52)
- Nitroglycerin patches applied over the damage tendon are thought to stimulate collagen production & vasodialation and have shown benefit in the treatment of elbow tendinopathies. (53)
- Surgical intervention should be considered for cases that are unresponsive after three to six months of care (54)
- Various surgical techniques exist to release the flexor origin and excise pathologic tissue. Good surgical outcomes have been demonstrated in greater than 80% of recalcitrant cases. (21)
At Creekside Chiropractic & Performance Center, we are highly trained to treat this condition. We are the only inter-disciplinary clinic in Sheboygan county that provides chiropractic, myofascial release, ART (Active Release Technique), massage therapy, acupuncture, physiotherapy, rehabilitative exercise, nutritional counseling, personal training, and golf performance training under one roof. Utilizing these different services, we can help patients and clients reach the best outcomes and the best versions of themselves. Voted best Chiropractor in Sheboygan by the Sheboygan Press.
Evidence Based-Patient Centered-Outcome Focused
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