GOLFER’S ELBOW/MEDIAL EPICONDYLITIS

Medial epicondylitis, commonly referred to as golfer’s elbow refers to the tendonitis/tendinopathy of the common flexor tendon  which is located at the medial aspect of the elbow. This is usually brought about by activities which put repetitive strain on the common flexor tendon. The usual culprits are sports involving an overhead throwing activity with Golfers contributing to a significant chunk of the sports related cases. The medial epicondyle is the bony point of origin for the  muscles constituting the common flexor tendon. These include the pronators and flexors of the forearm namely  pronator teres, flexor carpi radialis, palmaris longus, and flexor digitorum superficialis and flexor carpi ulnaris. While the flexor carpi ulnaris is innervated by the ulnar nerve , the rest of the muscles are innervated by the median nerve. Measuring roughly 3 cms long, extending beyond the medial ulnohumeral joint, the common flexor tendon traverses in a parallel orientation to the ulnar collateral ligament  behaving as a secondary stabilizer.

COMMON TERMINOLOGIES

• Medial Epicondylitis
• Medial Epicondylalgia
• Golfer’s elbow
• Pitcher’s Elbow
• Tendinosis/Tendinopathy of the common flexor tendon of the elbow

ETIOPATHOGENESIS

Hand and arm movements(including the wrist) such as grasping, lifting, twisting and bending may be responsible for the symptoms. Golfer’s elbow can either affect people who indulge in an activity causing overuse of the flexor muscles to which they are generally not used to or in people involved in activities causing daily repetitive strain on the flexor muscles. Although medial epicondylitis is commonly known as golfer’s elbow, it’s occurrence is much more common with other strenuous activities.

The common understanding is that activities constantly loading the common flexor muscles bring about micro tears at the base of the tendon leading to the natural inflammatory response of the body. This inflammation  which is associated with the typical pain can initially be intermittent but regular inflammatory episodes can lead to tendonitis. As it becomes chronic Tendinosis is seen to set in as remodelling of the collagen fibres takes place leading to a thickened tendon. It might be accompanied by calcification at times.

The likely causes may be

• Occupations demanding manual labour such as wood chopping, repairing automobiles, painting and hammering can produce repetitive load on the flexor muscles.
• Sporting activities such as golf, weightlifting or sports involving overhead throwing actions like javelin and short put can lead to medial epicondylitis.
• Working at a computer for long hours.
• Cooking involving regular chopping and peeling.

PREVALENCE

Golfer’s elbow is seen in less than 1% of the population. It is most commonly observed in patients lying between the ages of 40 to 60. It’s counterpart Tennis Elbow(lateral epicondylitis) is found to be much more common in the society. It has an equal preponderance towards men and women.

SYMPTOMS

• Patients usually complain of a dull aching pain on the medial/inner aspect of the elbow. The pain may radiate down from the bony prominence( medial epicondyle) to the forearm and wrist.
• The pain is aggravated by activities like writing and lifting which involve bending of the wrists. Sudden jerky movements as can happen while playing golf or overhead throwing games can lead to aggravation of the symptoms.
• The pain makes it hard to grasp objects and chronic cases may even report a  weakened grip strength.(possible ulnar nerve involvement) Rest usually resolves the symptoms but some patients report nagging pain disturbing their sleep as well.
• As high as 20% of the patients can have a concomitant finding of ulnar nerve involvement. These patients often report numbness and tingling along the ulnar nerve distribution along with weakness and stiffness felt at the elbow.

CLINICAL EXAMINATION

Patients can  present with swelling, redness  and warmth in acute cases  but chronic cases are unlikely to present with this symptom complex. Tenderness can elicited by palpation just anterior and distal to the medial epicondyle.

Clinical testing for golfer’s elbow/medial epicondylitis comprises of an active and a passive component.

For active component of the test, the patient is asked to resist wrist flexion with the arm in extension and supination. For the  passive component  wrist extension with the elbow in extension is included.[5,6] If pain is produced by these provocative manoeuvres, one should have a high clinical suspicion of golfer’s elbow. Ulnar neuropathy must be ruled out to complete the clinical examination. Tinel’s test should be performed to check for ulnar neuropathy.

On exam, there may be swelling, erythema, or warmth in acute cases; chronic cases are less likely to present with abnormalities on inspection. The patient will have tenderness over the five to ten millimeters distal and anterior to the medial epicondyle, especially near the conjoined tendon or muscles including pronator teres and flexor carpi radialis. Resisted pronation or flexion of the wrist elicits pain. The patient may be weak in the affected arm. The range of motion is typically normal.

The golfer’s elbow test or medial epicondylitis test involves an active and a passive component. In the active component, the patient resists wrist flexion with the arm in extension and supination. The passive component includes wrist extension with the elbow in extension. A test is positive when the patient endorses pain with this maneuver. [1,2]Tinel

‘s test should be used to evaluate for ulnar neuropathy, and the ulnar collateral ligament should be stressed especially in throwing athletes.

INVESTIGATION

Careful history and clinical examination are usually strongly indicative of the diagnosis but musculoskeletal ultrasound or MRI imaging of the elbow might be carried out to ascertain the findings.

TREATMENT

Conservative management is optimum in managing most cases of golfer’s elbow. This involves limitation of the offending activity as much as possible considering a person’s occupation. Medical management involves use of anti-inflammatory medications. Ice or cold packs can be helpful in times of inflammation. Modalities such as Ultrasound, shock wave  and electrical stimulation have been tried. Physical therapy should focus on eccentric exercises.  Correct Stretching and strengthening is a key component of the rehabilitation. Some patients might be advised night splints.

Anti Inflammatory injection- Corticosteroids can be injected blind or with image guidance on the inflamed surface to help relieve the inflammation so that the patient can start rehabilitation. Care should be taken not to give successive steroid injections at the same site

Platelet Rich Plasma with Prolotherapy

Treatment with Ultrasound guided Platelet Rich Plasma with Prolotherapy is an excellent treatment option as it brings about healing of the damaged tendon. Generally 2-3 sittings of Prp with prolotherapy coupled with regular exercises has been seen to be very effective in controlling the troublesome symptoms of golfer’selbow.

Stem Cells- Stem Cell injection into the damaged tendon has been tried for some chronic cases.

Surgery- Refractory cases ( which are pretty rare) may need surgical management. The surgery involves release of the common flexor tendon at the epicondyle and debridement of pathologic tissue. [3]

1. Budoff JE, Hicks JM, Ayala G, Kraushaar BS. The reliability of the Scratch test. J Hand Surg Eur Vol. 2008 Apr;33(2):166-9. [PubMed]
2. Polkinghorn BS. A novel method for assessing elbow pain resulting from epicondylitis. J Chiropr Med. 2002 Summer;1(3):117-21. [PMC free article] [PubMed]
3. Vinod AV, Ross G. An effective approach to diagnosis and surgical repair of refractory medial epicondylitis. J Shoulder Elbow Surg. 2015 Aug;24(8):1172-7. [PubMed]