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Golfer’s Elbow

What is medial epicondylitis also known as golfer’s elbow?

Medial epicondylitis, also known as golfer’s elbow, baseball elbow, suitcase elbow, or forehand tennis elbow, refers to the tendinitis of the common flexor-pronators musculotendinous insertion on the inside of the elbow at the medial epicondyle of the humerus. This is an extremely common injury that occurs due to overload of the tendinous tissue most often during tasks of high repetition.

How does golfer’s elbow occur?

Medial epicondylitis occurs with repeated or forced wrist extension/forearm supination during tasks that involve high load wrist flexion/pronation. This often has to be done at a frequency that causes tendinopathy that exceeds the tissues reparative capacity. Occasionally this condition can be the result of a single trauma/injury. Most often individuals will notice this occurring during racket, or club utilization. Examples are when someone swings a golf club or ax, pitches a baseball, carries a heavy suitcase, operates a chainsaw, or even types away on a keyboard. Research shows that the medial epicondylitis is the result of micro-tearing that can’t return to their previous state. This degeneration of fibers often causes abnormal collagen fiber arrangement, which can lead to calcification if the damaging and inflammatory conditions persist. These events cause the tendon to become less efficient at handling the tensile forces of normal musculotendinous function and it becomes more “fragile”. This leaves it more susceptible for further tendon damage/irritation to be accelerated due to further exacerbation as the loading of the structure exceeding the tissue capacity. Medial epicondylitis is often precipitated by poor body mechanics, improper techniques, and/or inadequate equipment or tools – which prevails compensation at the forearm and wrist.

What ligaments and structures are involved in golfer’s elbow?

Medial epicondylitis affects the tendons of flexor-pronator muscles that flex the wrist towards the palm, and rotate the forearm palm-down (pronation). The most common of these are flexor carpi radialis and pronator teres, which attach to the medial epicondyle of the humerus. Alongside them are flexor digitorum superficialis, flexor carpi ulnaris, flexor carpi radialis, and palmaris longus – which can also be affected.

What are the symptoms of golfer’s elbow?

The most common symptom of medial epicondylitis is pain and tenderness on the inside of the elbow, which can travel to the wrist. During the initial phases of the injury the pain may only occur after activity, but it may progress to the point where it begins to prevent activity participation. The pain is usually worse first thing in the morning, and is exacerbated with gripping and flexing wrist towards the palm – especially when resisted. A person’s grip is often weakened, but mostly due to pain inhibition. It is common to experience stiffness of the elbow after the elbow is not articulated frequently, and is most noted when the arm is fully extended or straightened.

How is golfer’s elbow diagnosed?

The diagnoses of medial epicondylitis primarily rely on clinical findings. The actual diagnosis is based on local pain at the medial elbow, and tenderness at the medial epicondyle. A patient will have an increase in pain at the elbow when performing gripping, resisted flexion of the wrist, and resisted pronation of the wrist. There are several special tests the healthcare provider will also employ to rule in or out medial epicondylitis. If the condition has persisted long enough or has significant findings a healthcare provider may also decide to do imaging to assess the integrity of the flexor-pronator tendons.

How is golfer’s elbow treated?

Nonoperative management is the most common method of treatment for medial epicondylitis. The sequence of recovery can be divided into 3 phases. Phase 1 consists of protecting the tendons, which involves cessation of aggravating activities and possible brace for the wrist. This phase is also involving pain-relieving modalities (ice, NSAIDs). Phase 2 consists of guided physical therapy, where therapists will help to achieve full and painless range of motion, followed by stretching and progressive isometric exercises – which eventually turn into resisted strengthening. The goal is to promote muscles to be stronger than they were pre-injury. Once exercises can be performed repeatedly without pain, phase 3 begins. Phase 3 consists of steady return to prior level of function and activities, with modifications to previously offending tasks to avoid re-injury. The timeline of these 3 phases varies based on patient presentation and severity of injury, however, if no improvement is noticed after 6-12 months, surgical management may be considered. This would involve debridement of the degenerated tendon, the release of the common flexor tendon at the medial epicondyle, and cortical drilling of the epicondyle to increase vascularity. Following the operation, recovery would involve initial splinting for 1 week, and physical therapy beginning 7-10 days post-op for range of motion. After 3-4 weeks, gentle isometric exercises are introduced. Progressive strengthening begins around 6-12 weeks, with patients returning to prior level and activities around 3-6 months post-operatively.

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