DESCRIPTION AND SYMPTOMS
What is medial epicondylitis?
- Golfer’s elbow can be defined as a tendinosis that affects the inside of the elbow, where the medial epicondyle is located. It is an injury that affects the flexor carpis radialis and the pronator teres.
- The injury is due to repetitive movements of the muscles responsible for facilitating the twisting of the wrist and the gripping function of the fingers.
- Although its name could lead to think that it is an injury exclusive to golf lovers, the truth is that it is also suffered by tennis players and other athletes, such as those who practice weightlifting, shot put, or javelin.
- Certain professionals such as carpentry, painting, masonry, assembly line operators or those who regularly work with a computer are also prone to suffering from medial epicondylitis.
Other injuries related to the wrist:
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What are the symptoms of golfer’s elbow?
Elbow pain that runs along the front of the forearm and reaches the wrist on the same side as the pinkie finger.- Pain when the wrist is flexed with the palm facing down. This tends to worsen when gripping with the hand or flexing the wrist.
- Night pain and trouble sleeping.
- Weak grip strength.
- Nerve damage to the ulnar nerve is relatively common, occurring in 30%-50% of patients, which causes tingling or numbness from the elbow to the pinkie and ring fingers.
Elbow pain that runs along the front of the forearm and reaches the wrist on the same side as the pinkie finger.If the injury is not treated in time
Work
Golfer’s elbow can negatively affect a person’s ability to perform work that involves the use of this part of the body.
Sport
If you suffer from this injury but continue to play sports, your injury will worsen and you will not be able to perform physical activities at 100% capacity.
Stiffness and Pain
Failure to treat the injury can lead to pain and difficulty moving the elbow.
How is medial epicondylitis prevented?
By performing stretching exercises before and after every day when sporting or professional activities occur.
By correcting your posture and movements during sporting or professional activities.
These preventative measures will be easier to put into place by consulting with a specialist who will help to detect which of your movements are being poorly performed and offer ways to improve them. Using adequate equipment and improving physical condition are other fundamental aspects of preventing medial epicondylitis that a professional can help you with.
If you play sports and want recommendations on how to improve your technique or specific exercises you can use before and after sporting activities to prevent damage, get in contact with us and we will email you more information.
DIAGNOSIS AND TREATMENT
How is medial epicondylitis diagnosed?
Diagnosis is made by the clinic with a physical examination, although complementary tests such as x-rays or MRI scans are sometimes also performed in order to confirm it.
- Tenderness on the inside of the elbow (or medial epicondyle).
- Pain when the wrist is flexed and forearm is moved side-to-side with counter-resistance applied.
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- Tingling in the ring and little finger when the nerve in the elbow is struck. (Positive Tinel’s sign in the ulnar nerve; present in 30%-50% of patients).
- Elbow instability. There are some misdiagnosed or “treatment refractive” medial epicondylitis. Ulnar collateral ligament injuries may be a cause.
How is media epicondylitis treated?
As it is a tendinosis (tendon inflammation), treatment for this injury begins conservatively:
- The first step is to stop doing the activity that is thought to be causing the injury. It is also advisable to rest and treat the tendon by applying ice packs to the medial epicondyle for about 15 minutes at a time, two to three times a day.
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- Non-steroidal anti-inflammatory drugs (NSAIDs) are also used to treat medial epicondylitis.
- A physical therapy program that includes stretching exercises aimed at strengthening the muscles and eccentric (contracting the muscle while simultaneously lengthening it) exercises should be undertaken in conjunction with painkillers. In some cases, it can also be necessary to perform corticosteroid or platelet-rich plasma injections to reduce pain.
If conservative treatment is ineffective and pain persists beyond 6-9 months, an orthopedic surgeon should assess the need of performing surgery; however only about 20% of median epicondylitis cases will require surgical treatment.
HOW IS SURGERY FOR GOLFER’S ELBOW PERFORMED?
Surgery, when necessary, is a minimally invasive procedure performed on an outpatient basis and with a high rate of success.
The type of surgery performed depends on whether the patient only has flexor tendon damage or if the ulnar nerve is also affected:
In cases where the ulnar nerve is not affected, surgery can be performed with a 2-3 cm incision to the inside of the elbow. It is a minimally invasive surgery and consists of simply removing this damaged tissue.
In cases where the patient has both nerve and tendon damage, open surgery is chosen. The incision is 3-4 cm to the inner edge of the elbow where tenotomy and nerve release are performed (for more information on the ulnar nerve, click here [link]).
The duration time for either surgery varies depending on factors such as the surgeon’s experience, the type of injury being treated, and the characteristics of the patient, but typically lasts between 30-45 minutes.
ELBOW INJURIES IN GOLFERS
In golf players, elbow injuries are mainly caused by overuse in training and not during competition, typically as a result of poor technique, and occur more frequently in amateur players (24%) rather than professionals (4%). They are more likely in the contralateral elbow (that is, the left elbow for right-handed golfers and vice-versa) and in players between the ages of 33 and 55.
Epicondylitis, both medial epicondylitis (“Golfer’s Elbow”) and lateral epicondylitis (“Tennis Elbow”), are due to an excessive use of the forearm muscles affecting, in 100% of cases, the extensor carpi radialis brevis, or 2nd Radial muscle (the muscle used to flex and twist the wrist) as well as (in 35% of cases) the fingers, affecting their ability to flex and extend. Interestingly, laterial epicondylitis injuries (“tennis elbow”, or damage to the tendons on the outer side of the elbow) are five times more frequent than medial epicondylitis (“golfer’s elbow”, or injury to the internal aspect of the elbow).
The cause of the injury is an intense and repetitive twisting movement with extension of the forearm and, although golf -especially at an amateur level, may appear to be less demanding sport, preventive measures are necessary to avoid injuries.
General recommendations for the prevention of elbow injuries:
Stretching and warming up before and after sports practice.
Strengthening of the forearm muscles. The can be achieved through use of low weights or elastic bands to improve overall physical condition.
Evaluating golf clubs and grip. Iron golf clubs are much heavier than graphite ones, for example, so it’s important to check if an injury has started with a change to either clubs or grip and choose the most appropriate.
To avoid elbow injuries, we should focus on the following technical aspects.
Avoid an excessively strong grip. That is, avoid holding the golf club with a lot of tension, which causes an eccentric contraction of the extensor muscles and overloads them. There are 3 types of golfing grips, and depending on which you use a prefer, there are some technical aspects you should pay attention to in order to avoid injury:
Vardon Overlap Grip, or Superimposed Grip (most commonly used by professional players): For right-handed players, hold the club in your left hand and place the pinkie finger of your right hand between the index and middle finger of your left hand.- Interlocking. Este grip es muy usado en personas con manos pequeñas (niños), debInterlocking Grip (widely used in people with small hands (children), muscular weakness and beginners; popularized by Jack Nicklaus and Tiger Woods): With the hands together, interlock the 5th finger of the right hand with the second finger of the left hand.
- Baseball Grip, or Ten Finger Grip (least commonly used; reduces the stress on the joints therefore more commonly used by people with joint problems): For right-handed players, simply hold your club with your right hand on top of your left.
In golf, the most important technical act is the swing. It is usually divided into four phases: set-up, back swing, downswing and followthrough. Proper swing technique is very important to avoid injury. To avoid injuries to the forearm when swinging we must:
- Avoid sudden impacts, such as hitting the ground or repetitive hits on hard surfaces.
- Avoid excessive flexing of the wrist while striking the ball.
- Pay careful attention to the downswing, or flexor burst. When performing this movement, there is great tension in the elbow and wrist so it must be controlled to order to avoid sudden changes in muscle contraction (from concentric to eccentric).
FREQUENTLY ASKED QUESTIONS
What is recovery like after surgery for medial epicondylitis?
After surgery for Golfer’s Elbow, the patient should heed the following guidelines:
- Apply ice packs 4-6 times a day on the dressing or bandage that covers the incisions, 20 to 30 minutes at a time. The ice should be wrapped in a towel or cloth so that it is not placed directly on the dressing.
- Take painkillers as prescribed by your doctor, which will help greatly to mitigate postoperative pain.
- Perform gentle movements with the arm. Even if the surgeon leaves a thick bandage or splint on after surgery, the patient must begin to move the arm gently in order to avoid so-called “rigid elbow.”
- Keep the bandage and wound clean and dry at all times. The bandage, splint, and stitches will be removed after about one week.
Is surgery the only way to treat golfer’s elbow?
No. Initially, the patient will have to undergo conservative treatment over a period of 6 months in order to study the injury and track the patient’s progress. If no improvement is observed, the recommendation will be to opt for arthroscopic surgery, which has a very high success rate.
What are the risks and side effects of surgery for medial epicondylitis?
After operation, residual pain is common and why painkillers are prescribed during initial postoperative recovery. Patients will also normally require a specialized rehabilitation program to avoid elbow stiffness.
What are the risks and side effects of surgery for medial epicondylitis?
After operation, residual pain is common and why painkillers are prescribed during initial postoperative recovery. Patients will also normally require a specialized rehabilitation program to avoid elbow stiffness.
REFERENCES
Zwerus EL, Somford MP, Maissan F, Heisen J, Eygendaal D, van den Bekerom MP.Br Physical examination of the elbow, what is the evidence? A systematic literature review.
J Sports Med. 2018 Oct;52(19):1253-1260. doi: 10.1136/bjsports-2016-096712. Epub 2017 Mar 1.PMID: 28249855
Meones M, Andrews K, Rowland A, Jain M, Mustapha AA, Skie M Clinical outcomes of combined surgical treatment of medial epicondylitis and cubital tunnel syndrome.
Hand Surg Rehabil. 2019 Oct;38(5):298-301. doi: 10.1016/j.hansur.2019.08.001. Epub 2019 Aug 9.PMID: 31404681
Brandon B, Pearce PZ. Training to prevent golf injury.Curr Sports Med Rep. 2009 May-Jun;8(3):142-6. doi: 10.1249/JSR.0b013e3181a61c88.PMID: 19436170
Lindsay DM, Horton JF, Vandervoort A review of injury characteristics, aging factors and prevention programmes for the older golfer.AA.Sports Med. 2000 Aug;30(2):89-103. doi: 10.2165/00007256-200030020-00003.PMID: 10966149
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