| Golfer's elbow | |
|---|---|
| Other names | Medial epicondylitis |
 | |
| Left elbow-joint, showing anterior and ulnar collateral ligaments. (Medial epicondyle labeled at center top.) | |
| Specialty | Orthopedics |
Golfer's elbow, ormedial epicondylitis, istendinosis (or more preciselyenthesopathy) of the medialcommon flexor tendon on the inside of theelbow.[1] It is similar totennis elbow, which affects the outside of the elbow at the lateral epicondyle. The tendinopathy results from overload or repetitive use of the arm, causing an injury similar toulnar collateral ligament injury of the elbow in "pitcher's elbow".[1]
The anterior-medial forearm contains several muscles that flex the wrist andpronate the forearm.[1] These muscles have a common tendinous attachment at themedial epicondyle of the humerus at the elbow joint.[1]
The flexor and pronator muscles of the forearm include thepronator teres,flexor carpi radialis,palmaris longus, andflexor digitorum superficialis, all of which originate on the medial epicondyle and are innervated by themedian nerve.[1] Theflexor carpi ulnaris muscle also inserts on the medial epicondyle and is innervated by theulnar nerve.[1] Together, these five muscles have a common attachment (anenthesis) on the medial epicondyle of the humerus.[1] The flexor tendon is approximately 3 centimetres (1.2 in) long, crosses the medial aspect of the elbow, and runs parallel to theulnar collateral ligament.[1]
The injury is not acuteinflammation, but rather is a chronic disorder resulting from overuse of a repetitive arm motion.[1][2] Repetitive activity leads to recurrent microtears within the flexor tendon, with remodeling of thecollagen fibers and an increase in the amount ofmucoidground substance.[1] As a result, scar tissue formation and thickening of the tendon lead to reduced collagen strength and pain with repetitive use.[1]
The condition is referred to asgolfer's elbow when a full golf swing causes elbow pain. It may also be calledpitcher's elbow due to the same tendon being stressed by repetitive throwing of objects, such as a baseball orfootball.[1][3][4]
Golfer's elbow appears to occur from repetitive full swings during the period from the top of the backswing to just before ball impact.[1] The full swing motion causes high energyvalgus forces during the late cocking (backswing in golf) and acceleration phase (downswing and impact).[1]
It is unknown whether this condition is any more common in labor-related occupations with forceful repetitive activities (such as in construction or plumbing) than it is in the general public.[1]
In adults, the pathophysiology may involvemucoid degeneration (disorganized collagen, increased extra-cellular matrix, and chondroid metaplasia).[5]
Medial epicondylitis is diagnosed based on characteristic pain with activities using strength in wrist flexion and confirmed on examination with discrete point tenderness over the common flexor origin at the medial epicondyle, and pain with resisted wrist flexion and passive wrist extension.[1][2][4][6]
Imaging may be employed, although radiography might show calcifications in the muscle origin.Ultrasound andmagnetic resonance imaging can identify the mucoid degeneration, but are not necessary for diagnosis.[1][2][4]
Medial injury of the flexor tendon is estimated to occur in 0.4% of the population.[1] It occurs most often in people ages 45 to 64, is more common in women than in men, and with 75% of cases in the dominant arm.[1]
Risk factors for developing golfer's elbow include improper technique or lack of strength, endurance, or flexibility.[1] Risk factors in people performing manual labor include heavy and excessive repetition, highbody mass index, the presence ofcomorbidities, and high work demands.[1]
Non-specific treatments include:[1][2][4]
Before anesthetics and steroids are used, conservative treatment with an occupational therapist may be attempted. Before therapy can commence, treatment such as rest, ice, compression and elevation (R.I.C.E.) will typically be used.[1][2][4] This will help to decrease the pain and inflammation; rest will alleviate discomfort because golfer's elbow is an overuse injury. The subject can use a tennis elbow splint for compression. A pad can be placed anteromedially on the proximal forearm.[7] The splint is made in 30–45 degrees of elbow flexion. A daytime elbow pad also may be useful, by limiting additional trauma to the nerve.[8]
Simple analgesic medication has a place, as does more specific treatment with oralanti-inflammatory medications.[1][2][4] These will help control pain and any inflammation.[7] A more invasive treatment is the injection into and around the inflamed and tender area of aglucocorticoid (steroid) agent.[9]
Therapy includes a variety of exercises for muscle and tendon reconditioning, starting with stretching and gradual strengthening of the flexor-pronator muscles.[2][4][6] Strengthening will slowly begin withisometrics and progresses toeccentric exercises helping to extend the range of motion back to where it once was. After the strengthening exercises, it is common for the subject to ice the area.[7]
After 6 months if the symptoms do not improve, surgery may be recommended.[1][2][4] Surgical debridement or cleaning of the area is one of the most common treatments.[6] The ulnar nerve may also be decompressed surgically.[7] If the appropriate remediation steps are taken – rest, ice, and rehabilitative exercise and stretching – recovery may follow. Few subjects will need to progress to steroid injection, and less than 10% will require surgical intervention.[7]Arthroscopy is not an option for treating golfer's elbow.[6]
