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.

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.

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.

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).

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

Treatment

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 NSAIDs

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

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.