01 Mar Golfers Elbow
Golfers Elbow or medial epicondylosis is very similar to the much more prevalent tennis elbow. It is a condition characterised by inflammation of the medial epicondyle as a result of strain upon several flexor tendons that originate there. Golfer’s elbow is characterized by pain, tenderness, stiffness and, of course, swelling of the affected elbow.
Despite the name, golfers elbow, there are a number of other non golf related activities that can result in medial epicondylosis. The injury generally occurs as a result of repetitive use of the wrist flexor muscles – wrist and finger flexion as seen in the standard golf grip – which have a common tendon attachment at the medial epicondyle. Micro tears usually form in the tendon over time as a result of repetitive lower grade forces but can occur with larger traumatic force such as driving a golf club into the ground with a golf swing.
Golfers elbow is equally common in men and women and peaks in prevalence between the ages of 35 and 45.
No one is immune from these injuries, but they are most common at the beginning of the golf season, or when the offending activity is increased in intensity or duration. Golf is one common cause of these symptoms, but many other sport- and work-related activities such as bricklaying can cause the same problem.
Another common cause of this injury is with weekend carpenters who use hand tools on occasion.
Symptoms of Golfers Elbow
Some people may also experience numbness or tingling in their 4th & 5th fingers as well as general weakness in the upper extremities. The ulnar nerve due to its close proximity to the medial epicondyle may become trapped in scar tissue.
Occasionally, golfers elbow can be associated with neck, shoulder or upper back pain on the same side. The condition can be either chronic or acute. In longstanding cases muscle weakness and reduced grip strength may also be present.
Pain in the elbow can also be referred from a source in either the shoulder or the neck; Physiotherapists are well equipped to asses and clear these areas before a definitive diagnosis of Golfers elbow is made. Further investigations such as an MRI scan or Ultrasound may be required, in rare cases, to confirm diagnosis.
Golfers elbow is characterised by:
- Pain and tenderness over the medial epicondyle often radiating down into the forearm
- Pain which is aggravated with resisted wrist flexion, pronation and gripping activities
- Pain with lifting or bending the arm
- Difficulty with extending the arm fully.
Management of Golfers Elbow
Most cases of golfers elbow settle well with appropriate physiotherapy. This includes careful assessment by the physiotherapist to determine which factors have contributed to the development of the condition, with subsequent correction of these factors. Management of golfers elbow involves rest from activity causing the irritation where possible or activity modification if complete rest is not an option. If the patient is unable to completely rest from aggravating activities, a compression strap may be a useful way of reducing strain on the painful area and allowing continued
Physiotherapy aimed at appropriate stretching and tissue release is also employed in order to offload the effected tissue and decrease pain. Acupuncture has also been shown to be effective in reducing pain and improving function of the arm. Ice and anti- inflammatory medication is also appropriate when inflammatory signs are present.
The second phase in management of Golfers elbow involves a programme of graduated eccentric loading of the effected tissue, which has been shown to give the best effect in stimulating the body to repair and strengthen the damaged tendon. Joint mobilisation and neural stretching may also ensure an optimal outcome and decrease the likelihood of future recurrence Research supports Physiotherapy combining elbow manipulation and exercise, as superior over the wait and see approach in the first six weeks and to corticosteroid injections after six weeks.
A graduated return to activity or sport carefully monitored by a physiotherapist is required in the final stages of treatment. This phase of treatment will also normally look at correcting the abhorrent biomechanics or work postures, which resulted in the injury as part of a return to full functional activity. Often the use of a golfers elbow brace or support can assist during this phase of the rehabilitation process.
With appropriate management, most minor cases of golfers’ elbow that have not been present for long can usually recover within a 6-8 weeks. In more severe and chronic cases recovery can be a lengthy process and may take up to 6 -12 months. Early physiotherapy intervention is therefore vital to hasten recovery.
Despite appropriate physiotherapy management, some patients with golfers elbow do not improve.
When this occurs the best course of management may include X-rays, ultrasound or MRI investigations and referral to an Orthopedic or Sports Physician.
When conservative measures fail, a steroid (cortisone) injection may be a reasonable option. If a patient has tried more than two cortisone injections without relief, it is unlikely that additional injections will improve the outcome.
Autologous Blood Injection & Platelet Rich Plasma Injection (involves injecting the tendon via ultrasound guidance with the patient’s blood) is a relatively new method for treatment of tendonosis harnessing the healing properties of blood from the platelet derived growth factor; some reports show up to 80% of patients obtain complete or significant pain relief following this procedure. If there has been no improvement after 4 weeks a second procedure may be indicated, rarely is a third injection indicated.
Surgery is indicated in less than 10% of Golfer’s elbow or medial epicondylosis cases, but if it is required, the most common is called the medial epicondyle release, in which the surgeon
debrides any scar tissue or irritated flesh from the medial epicondyle and the flexor tendon may also be sewn onto the nearby fascia, so that the irritation that is causing the inflammation is
reduced significantly. Occasionally ulnar nerve decompression is required.
All HNA physiotherapists are highly skilled in assessing and diagnosing golfers elbow.
We offer a complete solution to your patients’ problem, including treatment, activity modification and rehabilitation.
Please contact Noosa Sports & Spinal Physiotherapy Centre for further information on our services.
Information compiled by HNA Physiotherapist Kelly J Woosnam. References available on Request.