Golfers elbow (Medial Epicondylitis)

Golfers elbow, better termed a medial epicondylitis, results from an overuse injury and subsequent degeneration of the tendinous origin of the flexor pronator muscle mass at the elbow.

In golfers, this area is placed under valgus stress at the top of a backswing in golfing and proceeds through the downswing until impact with the golf ball.

The condition is also found in approximately 4% to 8% of workers in an occupational setting. Pain is elicited over the elbow’s medial epicondyle and is increased with resisted wrist flexion and forearm pronation. Management includes rest, ice, NSAIDs, and splints.

Steroid injections and surgery are rarely required. Steroid injections are controversial with evidence for short-term improvement but may result in tendon weakening.

Providers must be aware of the location of the ulnar nerve during injections in order to avoid any iatrogenic injury.

9 Interesting Facts of Medial Epicondylitis

1. Medial epicondylitis is the most common cause of medial elbow pain.
2. It is 5 to 10 times less frequent than lateral epicondylitis.
3. Occurs as a result of microtrauma and degeneration affecting the common flexor tendon origin at the medial epicondyle.
4. The pronator teres and flexor carpi radialis muscle origins are the most commonly involved
5. Repetitive activities involving eccentric contracture of the wrist flexors and forearm pronators and valgus overload of the elbow, such as with throwing, have been implicated as precipitating factors.
6. The most common cause is occupational.
7. Although medial epicondylitis is referred to as golfer’s elbow, only 10-20% of cases are due to recreational activities.
8. Acute injury is much more common than in lateral epicondylitis (up to one-third of cases), but most patients do not describe an inciting event.
9. It may be associated with ulnar neuropathy in as many as 50% of cases.

History

• •Medial epicondylitis typically occurs between ages 30 and 50.
• •Some studies suggest a female preponderance, while others indicate an equal distribution between men and women.
• •Patients may present with either insidious or more acute onset of medial elbow pain that localizes to the medial epicondyle and radiates into the forearm.
• •Symptoms are commonly activity related.
  • •Occupations that require repetitive or constant forceful gripping, lifting of loads greater than 20 kg, and vibratory forces, such as construction workers, plumbers, and carpenters
  • •Sports activities requiring repetitive wrist flexion and forearm pronation, such as golf, baseball, tennis, football, weight lifting, and bowling
  • •Throwers and tennis players describe increased discomfort in the late cocking and early acceleration phases of throwing/serving.
• •Concurrent diagnoses are common, especially in laborers.
  • •Ulnar neuritis, carpal tunnel syndrome, lateral epicondylitis, rotator cuff tendinitis/tear.

Physical Examination

• •Tenderness to palpation over the flexor-pronator origin at 5 to 10 mm distal/anterior to the medial epicondyle
• •Range of motion is frequently normal, but patients may present with an elbow flexion contracture (throwers).
• •Weakness with pronation compared to the contralateral side
• •Provocative tests:
  • •Increased pain with resisted wrist flexion and forearm pronation
  • •Forceful grip may be decreased compared to the contralateral side or exacerbate medial elbow pain.
• •Assess for concomitant conditions:
  • •Ulnar neuritis: Inflammation may cause irritation of ulnar nerve.
  • •Tinel sign over the cubital tunnel
    • •Decreased sensation: 2 point discrimination in the ulnar nerve distribution of the hand.
    • •Paresthesias with elbow hyperflexion for 30 to 60 seconds.
    • •Motor weakness or atrophy in the hand: Wartenburg and Froment signs.
  • •Ulnar nerve instability:
    • •Subluxation/dislocation and paresthesias with elbow hyperflexion
    • •Overdevelopment of the medial triceps head
  • •Ulnar collateral ligament (UCL) injury: Overhead athlete
    • •More distal apex of pain over sublime tubercle
    • •Milking test: Forearm is held in supination and valgus stress is applied to thumb through full range of elbow flexion and extension.
      • •Pain between 70 and 120 degrees of flexion indicates a positive test.
    • •Valgus stress test: Pain with valgus stress applied to elbow in 30 degrees of flexion, forearm pronation, and wrist flexion

Imaging

• •Radiographic assessment is rarely helpful in making what is largely a clinical diagnosis, but can be useful in ruling out other diagnoses with a similar presentation.
• •Radiographs: Anteroposterior and lateral views of the elbow
  • •Plain radiographs of the elbow may reveal calcification distal to the medial epicondyle (25% of cases).
  • •Rule out arthritis or acute osseous injury of the elbow.
• •Magnetic resonance imaging:
  • •Considered gold standard, indicated in unclear source of pain.
  • •May show degenerative changes in the flexor pronator mass.
  • •Assess integrity of the UCL.
  • •Rule out other soft-tissue pathology.
• •Ultrasound:
  • •Can be effective in experienced hands.
  • •Evaluate dynamically for complete disruption of tendon origin.

Differential Diagnosis

• •Cubital tunnel syndrome
  • •Positive Tinel sign, positive elbow hyperflexion test
• •Ulnar nerve subluxation
  • •Paresthesias and palpable anterior subluxation/dislocation of the ulnar nerve
• •UCL insufficiency: most common in overhead athletes.
  • •Common late finding in patients with chronic medial epicondylitis, as the intact common flexor tendon origin protects the underlying anterior bundle of the UCL.
• •Elbow arthritis
  • •Radiographic changes, crepitus, and/or mechanical symptoms with range of motion
• •Intra-articular elbow fracture
• •Triceps tendonitis
• •Snapping medial head of the triceps
  • •Mechanical snapping palpable with elbow range of motion; pain more posterior.
• •Cervical radiculopathy

Treatment

• •Nonoperative treatment
  • •Goals: relieve acute pain, rehabilitate the injured tendon, prevent recurrence
  • •Activity modification/rest: first line of treatment
    • •Avoid throwing/precipitating factors for 6 to 12 weeks in athletes.
    • •Passive stretching and icing
    • •Oral antiinflammatories: short 1- to 2-week course
    • •Bracing: counterforce bracing, nighttime splinting
      • •Kinesio tape effective in throwers.
      • •Nighttime extension bracing in patients with concomitant ulnar neuritis
  • •Extracorporeal shockwave therapy (ESWT)
    • •Thought to promote angiogenesis and healing while providing some analgesia.
    • •Some studies have shown long-term effectiveness, but inadequate data exists for definitive treatment recommendations.
  • •Cortisone injection
    • •Short-term benefit that has not been shown to persist at 3 or 12 months.
    • •Potential side effects: iatrogenic ulnar nerve injury, tendon degeneration, fat atrophy, skin pigmentation
  • •Platelet-rich plasma
    • •Has not been well studied in medial epicondylitis
    • •Same potential for iatrogenic nerve injury
  • •Ultrasound
  • •Physical therapy and rehabilitation
    • •Typically initiated once acute pain has subsided.
    • •Initial goal of restoring range of motion, followed by concentric and then eccentric strengthening
    • •Focus on prevention of recurrence
      • •Core and lower body strengthening in throwers
      • •Correct technique and equipment
• •Operative treatment
  • •Typically reserved for compliant patients who have not responded from 6 to 12 months of conservative treatment.
  • •Less success than surgery for lateral epicondylitis
  • •Open approach with resection of the diseased tendon and side-to-side or direct repair of the tendon origin is technique of choice.
  • •Mini open approach has been described with successful outcome, but may limit safe visualization of ulnar nerve.
  • •Arthroscopic debridement contraindicated due to potential for iatrogenic injury to the UCL and ulnar nerve.
  • •Ulnar nerve symptoms addressed by concurrent cubital tunnel release with or without ulnar nerve transposition.
• •Postoperative rehabilitation
  • •Short period of immobilization in a splint with elbow at 90 degrees of flexion is most common.
  • •Range of motion initiated at 2 weeks with return to light lifting and activities of daily living.
  • •Strengthening initiated at 6 weeks.
  • •Return to sports between 3 and 6 months.

When to Refer

• •Patients should be referred to a specialist for consideration of surgical treatment after failure of nonoperative treatment modalities for a minimum of 6 and 12 months.
• •UCL insufficiency or ulnar nerve symptoms on exam or imaging are an indication for referral.

Prognosis

• •Nonoperative treatment is successful in 90-95% of patients within 3 to 6 months.
• •Surgery is thought to be less successful than for lateral epicondylitis, with success rates reported between 83-96%.
• •Results are worse when ulnar nerve symptoms are present prior to surgery.

Troubleshooting

• •Younger patients, particularly overhead athletes, may present with subtle medial elbow instability that is difficult to distinguish clinically from medial epicondylitis. Magnetic resonance imaging may help to distinguish between these two entities.

Patient Instructions

• •Patient reassurance is of paramount importance. While most patients will not require surgical intervention, improvement can be slow and prolonged.
• •Patients should be instructed and show good understanding of therapy modalities, including activity modification, icing, stretching, and the use of nonsteroidal antiinflammatory medications.
• •Patients should be counseled on the potential benefits and risks for both nonoperative and operative treatment.
  • •Surgical benefits: decreased, but not necessarily resolved pain with the potential to return to previous activities
  • •Surgical risks: iatrogenic injury to the UCL, ulnar nerve, medial antebrachial cutaneous nerve (painful neuroma or patchy numbness in medial elbow), continued or recurrent symptoms
• •Following surgery, patients should be counseled on and demonstrate understanding of the postoperative therapy protocol.

Seek Additional Information

• Adams JE, Steinman SP, et al.: Elbow tendinopathies and tendon ruptures. In Wolfe SW, Hotchkiss RN, Pederson WC (eds): Green’s Operative Hand Surgery. 2017. Elsevier, Philadelphia pp. 863-884.
• Amin NH, Kumar NS, Schickendantz MS: Medial epicondylitis: evaluation and management. J Am Acad Orthop Surg 2015; 23: pp. 348-355.
• Badia A, Stennett C: Sports-related injuries of the elbow. J Hand Ther 2006; 19: pp. 206-226.
• Eygendaal D, Safran MR: Postero-medial elbow problems in the adult athlete. Br J Sports Med 2006; 40: pp. 430-434.
• Field LD, Savoie FH: Common elbow injuries in sport. Sports Med 1998; 26: pp. 193-205.
• Hume PA, Reid D, Edwards T: Epicondylar injury in sport: epidemiology, type, mechanisms, assessment, management and prevention. Sports Med 2006; 36: pp. 151-170.
• Vinod AV, Ross G: An effective approach to diagnosis and surgical repair of refractory medial epicondylitis. J Shoulder Elbow Surg 2015; 24 (8): pp. 1172-1177.