Medial epicondylitis is commonly known as golfer’s elbow. This does not mean that only golfers have this condition. But the golf swing is a common cause of medial epicondylitis. Many other repetitive activities can also lead to golfer’s elbow: throwing, chopping wood with an ax, running a chain saw, and using many types of hand tools.
Any activities that stress the same forearm muscles can cause symptoms of golfer’s elbow.
What parts of the elbow are affected?
Golfer’s elbow causes pain that starts on the inside bump of the elbow, the medial epicondyle. Wrist flexors are the muscles of the forearm that pull the hand forward.
The wrist flexors are on the palm side of the forearm. Most of the wrist flexors attach to one main tendon on the medial epicondyle. This tendon is called the common flexor tendon.
Tendons connect muscle to bone. Tendons are made up of strands of a material called collagen. The collagen strands are lined up in bundles next to each other.
Because the collagen strands in tendons are lined up, tendons have high tensile strength. This means they can withstand high forces that pull against both ends of the tendon.
When muscles work, they pull on one end of the tendon. The other end of the tendon pulls on the bone, causing the bone to move.
The wrist flexor muscles contract when you flex your wrist, twist your forearm down, or grip with your hand. The contracting muscles pull on the flexor tendon.
The forces that pull on the tendon can build when you grip a golf club during a golf swing or do other similar actions.
What are the symptoms?
Commonly, this occurs with pain and tenderness on the inside or medial side of the elbow, pain or weakness with gripping or twisting of the wrist, and pain with lifting objects
Why did I develop golfer’s elbow?
Overuse of the muscles and tendons of the forearm and elbow are the most common reason people develop golfer’s elbow.
Repeating some types of activities over and over again can put too much strain on the elbow tendons. These activities are not necessarily high-level sports competition.
Shoveling, gardening, and hammering nails can all cause the pain of golfer’s elbow. Swimmers who try to pick up speed by powering their arm through the water can also strain the flexor tendon at the elbow.
In some cases, the symptoms of golfer’s elbow are due to inflammation. In an acute injury, the body undergoes an inflammatory response.
Special inflammatory cells make their way to the injured tissues to help them heal. Conditions that involve inflammation are indicated by -itis on the end of the word.
For example, inflammation in a tendon is called tendonitis. Inflammation around the medial epicondyle is called medial epicondylitis.
However, golfer’s elbow often is not caused by inflammation. Rather, it is a problem within the cells of the tendon. Doctors call this condition tendonosis.
In tendonosis, wear and tear is thought to lead to tissue degeneration. A degenerated tendon usually has an abnormal arrangement of collagen fibers.
Instead of inflammatory cells, the body produces a type of cells called fibroblasts. When this happens, the collagen loses its strength.
It becomes fragile and can break or be easily injured. Each time the collagen breaks down, the body responds by forming scar tissue in the tendon. Eventually, the tendon becomes thickened from extra scar tissue.
No one really knows exactly what causes tendonosis. Some doctors think that the forearm tendon develops small tears with too much activity.
The tears try to heal, but constant strain and overuse keep re-injuring the tendon. After a while, the tendons stop trying to heal. The scar tissue never has a chance to fully heal, leaving the injured areas weakened and painful.
What is the treatment?
Step 1: Initially, treatment consists of anti-inflammatory medications and a stretching and strengthening program. Stretching is a key component in treating epicondylitis.
Each stretch should be held for at least 10 seconds, then relax the arm and repeat up to several times a day and in between activities. Minimally 3 sets of 20 repetitions should be performed.
Strengthening exercises will also help.
While doing any strengthening, exercises should always be pain free and done with a light weight and at least 3 sets of 20 repetitions.
Step 2: If symptoms continue after a trial of stretching and strengthening, you may benefit from a cortisone injection.
Cortisone decreases inflammation and increases blood flow to the area aiding healing. Most patients feel relief after one injection, but up to three cortisone injections over a period of time may be given.
Step 3: If stretching and strengthening, anti inflammatory medications and cortisone injections do not relieve symptoms, then surgery is an option.
Through a small incision over the bony prominence on the inside of the elbow, the base of the diseased tendon is removed and normal tendon tissue is reattached to the bone. This is an outpatient surgery.
How can my doctor be sure I have golfer’s elbow?
Your doctor will first take a detailed medical history. You will need to answer questions about your pain, how your pain affects you, your regular activities, and past injuries to your elbow.
The physical exam is often most helpful in diagnosing golfer’s elbow. Your doctor may position your wrist and arm so you feel a stretch on the forearm muscles and tendons.
This is usually painful with golfer’s elbow. Other tests for wrist and forearm strength are used to help your doctor diagnose golfer’s elbow.
You may need to get X-rays of your elbow. The X-rays mostly help your doctor rule out other problems with the elbow joint.
The X-ray may show if there are calcium deposits on the medial epicondyle at the connection to the flexor tendon.
Golfer’s elbow symptoms are very similar to a condition called cubital tunnel syndrome. This condition is caused by a pinched ulnar nerve as it crosses the elbow on its way to the hand.
If your pain does not respond to treatments for golfer’s elbow, your doctor may suggest tests to rule out problems with the ulnar nerve.
Related Document: A Patient’s Guide to Cubital Tunnel Syndrome
When the diagnosis is not clear, the doctor may order other special tests, such as a magnetic resonance imaging (MRI) scan or ultrasound.
An MRI scan uses magnetic waves to create pictures of the elbow in slices. The MRI scan shows tendons as well as bones.
Ultrasound tests use high-frequency sound waves to generate an image of the tissues below the skin. As the small ultrasound device is rubbed over the sore area, an image appears on a screen. This type of test can sometimes show collagen degeneration.
Recovery from surgery takes longer. Immediately after surgery, your elbow is placed in a removable splint that keeps your elbow bent at a 90-degree angle.
Ice and electrical stimulation treatments may be used during your first few therapy sessions to help control pain and swelling from the surgery.
Your therapist may also use massage and other types of hands-on treatments to ease muscle spasm and pain.
You will gradually work into more active stretching and strengthening exercises. You just need to be careful to avoid doing too much, too quickly.
Active therapy starts about two weeks after surgery. Your therapist may begin with light isometric strengthening exercises.
These exercises work the muscles of the forearm without straining the healing tissues. You will use your own muscle power in active range-of-motion exercises.
At about six weeks, you start doing more active strengthening. As you progress, your therapist will give you exercises to help strengthen and stabilize the muscles and joints of the wrist, elbow, and shoulder.
You’ll also do exercises to improve fine motor control and dexterity of the hand. Some of the exercises you’ll do are designed to work your hand and elbow in ways that are similar to your work tasks and sport activities.
Your therapist will help you find ways to do your tasks that don’t put too much stress on your elbow.
You may need therapy for two to three months. It may take four to six months to get back to high-level sports and work activities.
Before your therapy sessions end, your therapist will teach you a number of ways to avoid future problems.