Golfer’s elbow
Golfer's elbow affects the medial epicondyle whereas tennis elbow the lateral epicondyle

Definition

Golfer's elbow, or medial epicondylitis, is the inflammation of the medial epicondyle, a tendon located in the inner side of the elbow. Golf swing is often the cause of this condition, thus the origin of the name.

‍Overuse of the flexor and pronator muscles and tendons underlies Golfer's elbow pathology

Pathology

Golfer’s elbow is a similar but less common condition to tennis elbow, which occurs to the opposite, outer aspect of the elbow. It arises mainly from overuse of the muscles and tendons of the forearm, namely the flexor and pronator muscles (pronator teres and the flexor carpi radialis origins). 

These muscles function during forearm pronation and wrist flexion. With a golf swing the forces accumulate in the medial epicondyle tendon when griping the club. A continuous strain placed on these muscles with strenuous, repetitive movements can injure the medial epicondyle tendon creating microtears. It is believed that tendonosis (rather than tendonitis, or inflammation of the tendon), is the problem underlying medial epicondylitis. Tendonosis involves a gradual degeneration of the collagen fibres forming the tendon followed by the accumulation of cells called fibroblasts leading to scar formation, tendon rigidity and increased risk of rupture. 

Associated pathologies

Medial epicondylitis can be associated with ulnar neuropathy as well as changes in the medial collateral ligament. The involvement of the ulnar nerve is seen in approximately 50% of patients with Golfer’s elbow.

Colles' fracture with bone displacement seen before (left) and after closed reduction (right) in a cast

Classification

The fractures of the distal radius are defined with various classification systems including the AO (Arbeitsgemeinschaft fuer Osteosynthese) system. They relate to the mechanisms of injury and bone fracture characteristics and provide a guideline towards suitable treatments. The most frequent types of distal radius fracture are:

No 1.

Colles’ fracture is the most common type of fracture in which the distal bone of the radius tilts upwards following an outer bending of the wrist as it happens when falling on the hand

Smith’s fracture or reversed Colles’ fracture occurs when the distal portion of the radius tilts downwards following the inward bending of the wrist

Barton fracture is an intra-articular fracture of the distal radius with dislocation of the radiocarpal joint

Chauffeur fracture is an intra-articular fracture of the radial styloid process, also known as Hutchinson fracture or backfire fracture.

Left: Distal radius intraarticular, displaced fracture; Middle: Older distal radius fracture with callus formation; Right: Distal radius and ulna fracture, extraarticular and displaced

No 2.

Intra-articular fracture extends to the wrist joint (or articulation)

Extra-articular fracture is located outside of the wrist joint

Open fracture when bone fragments perforate the skin

Comminuted fracture when the bone breaks into multiple fragments

Non-displaced when the anatomical alignment of the bone is maintained or displaced when the bone fragments move apart.

Melone’s classification describes the characteristics of intra-articular fractures of the radius:

i    Stable fracture

ii    Unstable "die-punch"

iii   "Spike" fracture

iv Split fracture

v   Explosion injuries

Acetabular fracture of the pelvis

Acetabular fractures

These fractures are divided into:

Anterior pillar (not weight bearing part of joint)

Posterior pillar (often associated with dislocation of the hip including the weight bearing part of joint)

Transverse

Comminuted involving both column type 

Sacral / coccygeal fractures

The sacrum is a triangular-shaped bone formed by 5 fused vertebrae, which provide a posterior wall to the pelvic ring. At each side of the sacrum, the ala structures articulate with the ilium bones forming the sacro-iliac joints. Sacral fractures are usually parallel to the spine and can involve the ala. Less frequently sacral fractures may display an “H” shape, including a transversal fracture uniting both sides of the sacrum. Three zones are described where sacral fractures can occur that are along vertical lines relative to the alignment of the foramina. Sacral fractures may result in sacral instability and require treatment via sacroplasty (injection of bone glue into the fracture). Surgery is necessary in case of associated neurological symptoms.

Fractures of the coccyx involve the tailbone, the terminal portion of the spine situated below the sacrum formed by 3 to 5 fused vertebrae. Coccyx fractures occur when falling on a seated position. They are more common in elderly women and seldom require surgical treatment.

Golfing is the most frequent cause of medial epicondylitis

Causes

Medial epicondylitis is common in individuals between 35 and 55 years of age. Overuse is the main cause of this pathology especially in older people as the tendons become weaker with ageing. It mostly develops with swing movements of the wrist typical of golfing or throwing activity in ball sports, bowling, weight lifting and arching and racquet sports. It can also arise from a wrong posture, when working at a computer desk, driving and DIY activities or sudden trauma.

Not only golfing poses a risk of the disease. Logging is also a risk factor

Risk factors

There are a number of predisposing risk factors for medial epicondylitis:

Golfing

Racquet sports

Throwing sports

Muscle weakness

Poor flexibility of the forearm

Training errors

Improper technique

Wrong equipment

Manual occupations involving repetitive wrist flexion and forearm pronation (carpentry, manufacturing, sewing, logging).

Goler's elbow manifests with pain when twisting the wrist in a prone position

Symptoms

Signs of a Golfer’s elbow typically increase gradually and possibly last several weeks or longer. The most common symptoms of Golfer's elbow are:

Pain on the inside edge of the elbow, which can extent to the lower arm when gripping objects

Pain during wrist flexion and pronation

Tenderness when touching the anterior aspect of the medial epicondyle and proximal flexor pronator mass

Weakening of the forearm muscles involved in gripping

Medical examination for the diagnosis of Golfer's elbow

Diagnosis

The clinical presentation is usually the best method for the diagnosis of Golfer's elbow. The patient’s history of sport or profession involving physical activities posing a risk for this pathology and past injuries will be discussed with the examiner. 

Clinical investigation focuses on the characteristics of pain at rest and during elbow activity, tenderness at touch and changes in the range of movement. Ultrasound is often sufficient to detect changes in the structure of the tendon including the presence of tears and swelling.

X-rays are only taken to exclude arthritis to the elbow or other bone-related conditions and visualise calcium deposits in the tendon. MRI is only rarely recommended. Electrodiagnostic studies are undertaken with suspected injury to the ulnar nerve, the median nerve or the medial antebrachial cutaneous nerve.

Treatment

Local injection of steroids reduces inflammation in a prolonged Golfer's elbow

Nonoperative treatment

Conservative treatment is routine in 90-95% patients and symptoms normally improve over 4-6 weeks. However, relapses are common 3 to 4 months later. The following management is standard for treating Golfer's elbow:

Rest

Oral administration of NSAID’s

Local injections of steroids and/or analgesics

Bracing over the flexor pronator and a wrist splint

Platelet rich plasma injection

Laser therapy

Extracorporeal shock wave therapy

Botox injection

Physical therapy

Example of arthroscopic surgery

Surgical treatment

If symptoms of Golfer’s elbow do not improve with conservative treatment, surgery may be necessary. This includes procedures to the medial epicondylitis, the medial conjoint tendon and ulnar nerve to repair the damaged tendon and release or partially debride the origin of the flexor muscle. In some cases, the medial conjoint tendon is fully excised. Surgery can be performed via open approach or arthroscopy. Return to sport may take longer, up to 6 months after surgery.

Stretching exercise of the elbow guided by a physiotherapist

Rehabilitation

Following surgery a splint is worn for two weeks with the elbow kept at 90º before commencing active physiotherapy. Physical exercise is critical for the treatment of Golfer’s elbow, whether operated or not, and offers a variety of approaches:

Rest

Ice application

Soft tissue massage

Electric stimulation

Ultrasound

Taping or bracing

Joint mobilisation

Ice or heat

Progressive exercises to improve flexibility and strength

Postural correction

Treatment of any related injuries (neck, shoulder or upper back)

Progressive wrist flexion and forearm pronation

Learning good sport techniques can prevent injuries such as Golfer's elbow

Prevention

Golfer's elbow can be prevented with the introduction of simple measures when practicing sport or other physical activities. They include:

Stretching exercises before and after golfing/other sports

Warm up before sport

Patient education, activity modification

Avoid weight lifting

Ergonomic assessment of workplace

Maintain muscle strength with regular exercise

Use of taping, straps to minimise forearm muscle strain