Golfers Elbow (Medial Epicondylitis)

What is Golfers Elbow (Medial Epicondylitis)?

Medial epicondylitis, also known as golfer’s elbow, is a condition where the tendon in your elbow becomes painful and tender due to excessive use or strain. It is also sometimes called a pitcher’s elbow, or defined using medical terms like tendinosis or epicondylalgia.

The inside (medial) part of your elbow is where the muscles that help flex (bend) your arm and hand, and turn your forearm inward come together. These muscles include the pronator teres, flexor carpi radialis, palmaris longus, and flexor digitorum superficialis. They attach to your elbow at the same spot and are controlled by the median nerve. The flexor carpi ulnaris, controlled by the ulnar nerve, also connects at this point.

These five muscles together form a tendon that attaches to your upper arm bone (humerus) on the inside of your elbow. This tendon is about three centimeters long, crosses over the inside part of your elbow joint, and runs alongside the ulnar collateral ligament, which it helps stabilize.

What Causes Golfers Elbow (Medial Epicondylitis)?

Medial epicondylitis, often referred to as “golfer’s elbow”, can happen due to various activities. It’s common in sports like golf, American football, tennis and other racquet sports, archery, bowling, weightlifting, and javelin throwing. In particular, pitchers and athletes who throw overhead often get this condition. It happens due to forces being exerted on the inside of the elbow during the act of throwing.

For golfers, it usually happens between when the club is raised in the backswing and just before hitting the ball. But, it’s important to note that more than 90% of medial epicondylitis cases aren’t related to sports. Jobs that involve forceful, repetitive actions like carpentry, plumbing, and construction are also common causes of medial epicondylitis.

Risk Factors and Frequency for Golfers Elbow (Medial Epicondylitis)

Medial epicondylitis, while not as common as lateral epicondylitis, still makes up 10% to 20% of all epicondylitis cases. One study shows a prevalence of 0.4% in the population. This condition is most common among people between the ages of 45 and 64, and it’s more common in women than in men. Some jobs may see an even higher prevalence, ranging from 3.8% to 8.2%. Also, three out of four cases are in the arm that the person uses the most.

Risk factors for developing medial epicondylitis in athletes include training mistakes, incorrect technique, inappropriate equipment, or lack of strength, endurance, or flexibility.
For those in certain occupations, the risk factors can be heavy physical work, repetitive tasks, being overweight, smoking, having co-existing health problems, and high work-related stress.
General risk factors also include smoking and having type 2 diabetes. Women who are obese are at increased risk.
Interestingly, it’s less common in those with a higher level of education, and there’s no clear link with exercise, leisure, or recreational activities.

Signs and Symptoms of Golfers Elbow (Medial Epicondylitis)

Patients with golfer’s elbow, or medial epicondylitis, usually report a history of sudden trauma or repetitive elbow use such as gripping, or applying inward stress on their elbow. They often describe aching pain on the inner side of the elbow, which extends down into the forearm and wrist. This pain can manifest slowly over time, though sudden, acute injuries can also happen. Activities like forearm movement, gripping, or throwing can exacerbate the pain, but it usually decreases when the activity is stopped. These activities include overhead throwing, tennis, and golf. Other reported symptoms may include stiffness or weakness in the elbow, or a sensation of numbness or tingling, particularly in the distribution of the ulnar nerve. More severe or long-term cases can involve a weakening of grip strength. It’s estimated that nearly 20% of patients may report symptoms associated with the ulnar nerve.

When examined, these patients sometimes show signs like swelling, redness or heat in their elbow in acute cases, while chronic cases are less likely to exhibit abnormalities on visual inspection. Medical professionals often find that patients have tenderness or pain roughly 5 to 10 millimeters below and in front of the medial epicondyle, particularly around the area containing the pronator teres and flexor carpi radialis muscles. Pain can be elicited by asking the patient to resist protracting their arm or flexing their wrist. Despite the pain, patients usually have normal range of motion in the affected arm.

Testing for golfer’s elbow usually involves an active and a passive component. In the active test, the patient tries to resist moving the wrist while the arm is fully extended and turned upward. In the passive test, the wrist is extended while the elbow is also fully extended. Pain during these movements indicates a positive test result. On a side note, the Tinel’s test is usually done to evaluate symptoms of ulnar nerve issues. If the patient is an athlete who engages in throwing sports, their ulnar collateral ligament should be closely examined for any signs of damage.

Testing for Golfers Elbow (Medial Epicondylitis)

When diagnosing medial epicondylitis, also commonly known as golfer’s elbow, your doctor will primarily use a physical examination. Medial epicondylitis is a type of pain that occurs on the inside of the elbow, usually caused by overuse during certain activities.

Though not the main method of diagnosis, X-rays can be helpful to rule out other causes of elbow pain. In some cases, X-rays may show bone changes or damage to the tendons, but this only happens in about 20% to 30% of patients. In children, if the diagnosis is uncertain and their bones are still growing, an X-ray of the unaffected arm might be necessary for comparison purposes.

Ultrasound, which uses sound waves to create images of the inside of your body, can be a quick and cost-effective way to examine the muscles and tendons in the elbow, and help rule out other possible causes for the pain. Ultrasound is highly accurate for diagnosing medial epicondylitis, and it allows the doctor to examine the elbow in motion. In chronic (long-term) cases, parts of the tendon might appear less bright (hypoechoic) on the ultrasound image.

Magnetic resonance imaging (MRI) is the gold standard for diagnosing medial epicondylitis, but it’s generally used to exclude other possible causes of elbow pain, such as a ligament strain or tear, a bone condition known as osteochondritis dissecans, or other soft tissue injuries. A bone scan and computed tomography (CT scan) might also be used to rule out other potential causes. If your doctor is concerned about involvement of the ulnar nerve (a nerve that runs down the arm and through the elbow), you might have an electromyogram and nerve conduction studies. These tests measure the electrical activity in your muscles and the speed of nerve signals to help detect any nerve damage.

Treatment Options for Golfers Elbow (Medial Epicondylitis)

Medial epicondylitis, often called golfer’s elbow, is a condition that can be more challenging to treat than lateral epicondylitis, also known as tennis elbow. However, the majority of cases can be managed without surgery.

In the beginning, the best treatment is generally to stop or reduce activities that are causing your symptoms. This might mean doing less of certain activities or doing them less intensely. This is not always possible, particularly for people who need to do these activities for their job or sport.

Pain relief medications such as non-steroidal anti-inflammatory drugs (like Ibuprofen) and acetaminophen (also known as Paracetamol) can help manage the symptoms. Opioids aren’t recommended for this condition. Putting ice on the affected area, particularly after you’ve been using it, can also help. There are also patches you can apply that have nitroglycerin in them which can be useful for this sort of injury.

Physical therapy, exercises specifically designed by healthcare professionals, is often the main form of treatment. The aim is to try and regain full, painless movement in your wrist and elbow. A range of methods might be used in physical therapy, including dry needling (inserting a needle into areas of the muscle), shock wave therapy, electrical stimulation, iontophoresis (using an electrical current to deliver medication), and ultrasound. Also, soft tissue manipulation and stretching exercises may help speed up recovery.

Wearing a splint at night can prove helpful. Also, during the day a brace or taping your elbow can help to reduce the load on the tendon and lessen the pain.

In cases where pain persists, other treatments may be considered. These can include injections directed by ultrasound or manual palpation, using medications like corticosteroids, platelet-rich plasma (a product made from your own blood), Botox (often used for wrinkles), or a treatment called prolotherapy. Percutaneous tenotomy, a minimally invasive procedure that involves making a small cut in the tendon, may be another option.

Finally, if all other treatments haven’t helped, surgery might be needed, although this is quite rare. Options for surgery may involve releasing the flexor tendon from the bone at the elbow where it attaches, removing unhealthy tissue, or a technique known as Fascial Elevation and Tendon Origin Resection (FETOR).

When a physician is diagnosing medial epicondylitis (also known as “golfer’s elbow”), there are many different conditions that could potentially be the cause. These might include:

Neuropathy (nerve-related conditions), such as C6 or C7 radiculopathy, cubital tunnel syndrome, ulnar or median neuropathy, ulnar neuritis, anterior interosseous nerve entrapment, or tardy ulnar nerve palsy.
Ligamentous injury (issues with the ligaments), such as ulnar or medial collateral ligament instability, sprain, or tear.
Intra-articular issues (problems within the joint itself), like adhesive capsulitis, arthrofibrosis, or loose bodies.
Osseous concerns (bone-related conditions), such as medial epicondyle avulsion fracture, or osteophytes.
Myofascial difficulties (issues with the muscles and the connective tissue that surrounds them), including flexor or pronator strain.
Tendinopathy (tendon injuries), such as lateral epicondylitis, triceps tendonitis.
Synovitis (inflammation of the synovial membrane).
Valgus extension overload (a type of injury often seen in athletes who do a lot of throwing).
Dermatologic concerns (skin-related conditions), like herpes zoster.

This means the physician has to consider a wide range of possibilities and perform the appropriate tests to reach the correct diagnosis.

What to expect with Golfers Elbow (Medial Epicondylitis)

The outlook for medial epicondylitis, also known as golfer’s elbow, is generally positive. Most patients are likely to be able to get back to work or their sports activities once they have finished their physical therapy and made necessary changes to their activities.

Possible Complications When Diagnosed with Golfers Elbow (Medial Epicondylitis)

The main issue with medial epicondylitis, also known as golfer’s elbow, is that the pain can stick around for a long time. Patients might also experience pressure on the ulnar nerve (the nerve running along the inner side of the arm), an injury to the ulnar collateral ligament in the elbow, or other related conditions. These related conditions can include carpal tunnel syndrome (a condition affecting your hand and wrist), lateral epicondylitis (also known as tennis elbow), or rotator cuff tendinitis (a shoulder issue).

If the condition is managed with surgery there could be some complications such as a nerve neuropathy (an issue with the nerves near the inner side of the lower arm), injury to the ulnar nerve, or an infection.

Common side effects:

Persistent pain
Pressure on the ulnar nerve
Injury to the ulnar collateral ligament
Carpal tunnel syndrome
Lateral epicondylitis (Tennis Elbow)
Rotator cuff tendinitis
Medial antebrachial cutaneous nerve neuropathy
Ulnar nerve injury
Infection (post-surgery)

Recovery from Golfers Elbow (Medial Epicondylitis)

The doctor’s personal approach often determines the type of care and rehabilitation provided after surgery. Care after surgery generally begins with a focus on reducing pain and swelling. This is followed by exercises to improve the patient’s range of motion gradually, along with strengthening exercises and stretching. The final stage of recovery aims to help the patient return to their regular activities.

Preventing Golfers Elbow (Medial Epicondylitis)

No official guidelines have been established yet for preventing medial epicondylitis, a condition causing pain on the inner side of the elbow (also known as ‘golfer’s elbow’). However, to prevent conditions linked to tendon damage, such as tendinitis and tendinopathy, it is generally advised to avoid doing too much of the activity or movements that initially caused the problem.

For those who have previously suffered from medial epicondylitis and recovered, continuing with follow-up physical therapy sessions could potentially help prevent the condition from returning. This is because physical therapy can strengthen and increase the flexibility of muscles and tendons, reducing the risk of injuring them in the future.

Frequently asked questions

Golfer's elbow, also known as medial epicondylitis, is a condition where the tendon in the elbow becomes painful and tender due to excessive use or strain.

Medial epicondylitis, or golfer's elbow, makes up 10% to 20% of all epicondylitis cases and has a prevalence of 0.4% in the population.

Signs and symptoms of Golfers Elbow (Medial Epicondylitis) include: - Aching pain on the inner side of the elbow, which extends down into the forearm and wrist. - Pain that can manifest slowly over time or occur suddenly due to acute injuries. - Exacerbation of pain with activities such as forearm movement, gripping, or throwing, but it usually decreases when the activity is stopped. - Activities that can worsen the pain include overhead throwing, tennis, and golf. - Other reported symptoms may include stiffness or weakness in the elbow, or a sensation of numbness or tingling, particularly in the distribution of the ulnar nerve. - More severe or long-term cases can involve a weakening of grip strength. - Approximately 20% of patients may report symptoms associated with the ulnar nerve. - Signs of swelling, redness, or heat in the elbow may be present in acute cases, but chronic cases are less likely to exhibit abnormalities on visual inspection. - Tenderness or pain around 5 to 10 millimeters below and in front of the medial epicondyle, particularly around the area containing the pronator teres and flexor carpi radialis muscles. - Pain can be elicited by asking the patient to resist protracting their arm or flexing their wrist. - Normal range of motion in the affected arm is usually maintained. - Testing for golfer's elbow involves active and passive components, with pain during wrist movement indicating a positive test result. - The Tinel's test is usually done to evaluate symptoms of ulnar nerve issues. - Athletes who engage in throwing sports should have their ulnar collateral ligament closely examined for any signs of damage.

Golfers Elbow (Medial Epicondylitis) can be caused by various activities such as golf, American football, tennis, other racquet sports, archery, bowling, weightlifting, and javelin throwing. It can also be caused by jobs that involve forceful, repetitive actions like carpentry, plumbing, and construction.

The other conditions that a doctor needs to rule out when diagnosing Golfers Elbow (Medial Epicondylitis) include: - Neuropathy (nerve-related conditions), such as C6 or C7 radiculopathy, cubital tunnel syndrome, ulnar or median neuropathy, ulnar neuritis, anterior interosseous nerve entrapment, or tardy ulnar nerve palsy. - Ligamentous injury (issues with the ligaments), such as ulnar or medial collateral ligament instability, sprain, or tear. - Intra-articular issues (problems within the joint itself), like adhesive capsulitis, arthrofibrosis, or loose bodies. - Osseous concerns (bone-related conditions), such as medial epicondyle avulsion fracture, or osteophytes. - Myofascial difficulties (issues with the muscles and the connective tissue that surrounds them), including flexor or pronator strain. - Tendinopathy (tendon injuries), such as lateral epicondylitis, triceps tendonitis. - Synovitis (inflammation of the synovial membrane). - Valgus extension overload (a type of injury often seen in athletes who do a lot of throwing). - Dermatologic concerns (skin-related conditions), like herpes zoster.

The types of tests that a doctor may order to properly diagnose medial epicondylitis (golfer's elbow) include: 1. Physical examination: This is the primary method of diagnosis for medial epicondylitis. The doctor will assess the symptoms and perform specific tests to evaluate the elbow. 2. X-rays: X-rays may be used to rule out other causes of elbow pain. They can show bone changes or damage to the tendons, although this is not common in medial epicondylitis. 3. Ultrasound: Ultrasound uses sound waves to create images of the muscles and tendons in the elbow. It is highly accurate for diagnosing medial epicondylitis and allows the doctor to examine the elbow in motion. 4. Magnetic resonance imaging (MRI): MRI is the gold standard for diagnosing medial epicondylitis. It is primarily used to exclude other possible causes of elbow pain and to assess soft tissue injuries. 5. Electromyogram and nerve conduction studies: If there is concern about involvement of the ulnar nerve, these tests may be performed to measure the electrical activity in the muscles and the speed of nerve signals. Other tests that may be used to rule out other potential causes of elbow pain include bone scans and computed tomography (CT) scans.

Golfer's Elbow (Medial Epicondylitis) can be treated in several ways. Initially, it is recommended to reduce or stop activities that are causing symptoms. Pain relief medications like non-steroidal anti-inflammatory drugs and acetaminophen can help manage the pain. Applying ice to the affected area and using patches with nitroglycerin can also provide relief. Physical therapy, including exercises, dry needling, shock wave therapy, and ultrasound, is often the main form of treatment. Wearing a splint at night and using a brace or taping during the day can reduce the load on the tendon. In cases where pain persists, other treatments like injections, corticosteroids, platelet-rich plasma, Botox, or prolotherapy may be considered. Surgery is a rare option and may involve releasing the flexor tendon, removing unhealthy tissue, or using a technique called Fascial Elevation and Tendon Origin Resection (FETOR).

The side effects when treating Golfers Elbow (Medial Epicondylitis) can include persistent pain, pressure on the ulnar nerve, injury to the ulnar collateral ligament, carpal tunnel syndrome, lateral epicondylitis (Tennis Elbow), rotator cuff tendinitis, medial antebrachial cutaneous nerve neuropathy, ulnar nerve injury, and infection (post-surgery).

The prognosis for Golfers Elbow (Medial Epicondylitis) is generally positive. Most patients are likely to be able to get back to work or their sports activities once they have finished their physical therapy and made necessary changes to their activities.

You should see a healthcare professional, such as a primary care physician, orthopedic specialist, or sports medicine specialist, for Golfers Elbow (Medial Epicondylitis).