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.
Tennis elbow is more common but golfer’s elbow remains the most reported pain problem over the inner elbow. Men are more likely to be sufferers than women in a 2:1 proportion, with most people affected in their early adult or middle years. The dominant hand is typically affected in two-thirds of cases, a third report a sudden pain onset with pain coming on slowly over time in the rest.
Typical symptoms are an ache or pain over the front of the inner elbow which is worsened by repeated wrist bending and improved by rest. Hand, forearm, elbow and shoulder pain may be reported, with grip weakness in the hand. If the ulnar nerve is involved this can also contribute to the weakness and give pins and needles in the forearm. The physio palpates the muscles and their tendinous insertions, the elbow joints and the groove behind the elbow where the ulnar nerve lies. To exclude other significant diagnoses the physiotherapist will perform a neurological examination.
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.
Non-steroidal anti-inflammatory drugs are used by physios in the initial acute phase to reduce pain and inflammation along with avoiding painful movements, use of ice, gentle stretches, friction massage and ultrasound. As the problem settles and becomes sub acute the aims change to improving flexibility by stretching, increasing strength and normal activities. A forearm brace may also be used or a wrist brace to rest the wrist muscles. Once the problem is chronic the programme continues with reduced use of the splint and re-introduction of sporting activities.
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.
Advice from a professional instructor is well worthwhile as they can instruct on technique of the golf swing, aerobic fitness, muscle strength work and flexibility. Warming up prior to activity and stretching afterwards, with good sporting technique and sound choice of equipment are the basic requirements. Monitoring of patients by the physiotherapist, especially if they are sports people, may be essential to avoid overdoing and training or performing through pain.
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