Golfers elbow (medial epicondylitis) is not confined to golfers, but occurs in many sportsmen and women, with racquet sports the most common causes. Other sports where golfers elbow occurs are in bowlers in cricket, archers and weightlifters. This and the more common tennis elbow are tendinopathies, overuse syndromes where there is no significant inflammation but a pathological alteration in the body of the tendon at the painful site.
The forearm muscles, which flex and rotate the forearm, originate in tendon-like tissue at the medial epicondyle, the bony lump on the inside part of the elbow. Due to the lack of inflammation the term tendonitis is not correct and tendinopathy, an internal process of degeneration, is the preferred term. Any activity which pushes the lower arm outwards away from the body, into so-called valgus or knock elbow, puts extra force on the muscles of the flexor origin which are resisting the movement.
High stresses occur in the cocking phase of a throw and during the subsequent acceleration, and in the golf swing from high backswing down to near the ball strike. Golfers are more likely to have their dominant hand affected and tennis players who use heavy topspin in their forehands are also more at risk. Golfers elbow is the most common cause of pain over the inside of the elbow and less common than tennis elbow. Twice as many men are affected as women, with people being affected initially mostly in their twenties to their forties. Golfers elbow presents in the dominant hand in 60% of occurrences, with 30% of sufferers reporting a sudden and painful onset, the remainder having a slow onset.
Patients complain of aching pain over the front of the inner epicondyle, worse with repeated wrist flexion and better with rest. Pain can occur in the shoulder, elbow, forearm or hand, with weakness in the lower arm and hand also. The osteopath will examine the bony areas and joints of the elbow, check the muscles and their tendinous insertions. The osteo palpates the ulnar nerve in the groove behind the elbow, called the funny bone when its hit. The nerve can give pins and needles or weakness in the forearm and a neurological examination excludes other causes of pain or weakness.
Most golfers elbow treatment is conservative, not surgical. Treatment involves activity modification, forearm or wrist splinting, anti-inflammatory drugs, steroid injections and osteopathy. Modification of the use of the arm is vital to prevent ongoing stimulation of the condition, so altering the mechanics of swinging the golf club or other sporting equipment is essential. Patient education continues with the identification of aggravating activities and postures and the patient is taught to avoid them.
Non-steroidal anti-inflammatory drugs are used by physios in the initial acute phase to reduce pain and inflammation along with avoiding painful movements, use of ice, gentle stretches, friction massage and ultrasound. As the problem settles and becomes sub acute the aims change to improving flexibility by stretching, increasing strength and normal activities. A forearm brace may also be used or a wrist brace to rest the wrist muscles. Once the problem is chronic the programme continues with reduced use of the splint and re-introduction of sporting activities.
Corticosteroid injections are commonly used for treatment of longer term medial epicondylitis but are more useful early on in the management of golfers elbow to relieve pain. Laser and shockwave therapy have no good evidence for usefulness. Surgery is only considered once conservative osteopathy has failed. Surgery is used to debride the abnormal tissue from the affected area and in the cases of nerve involvement to move the ulnar nerve from its groove round to the front of the elbow.
Correction of sporting technique, such as the golf swing, is best achieved by engaging a professional instructor who can also advise on stretches, fitness work and muscle strengthening. Athletes should warm up well before sport and stretch effectively afterwards, choosing good technique and selection of appropriate equipment. Doctors and osteotherapists may need to monitor patients, especially athletes, very carefully as they tend to continue to perform through the pain.
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