Golfer's elbow

Alternate names

• Medial Epicondylitis
• Pitcher's elbow

Definition

• Golfer’s elbow (medial epicondylitis or pitcher's elbow) is tendinopathy caused by overuse or overload and affects the medial common flexor tendon of the elbow. This may present insidiously with patients reporting an aching pain that radiates from the Epicondyle down to the wrist.

Etiology

• Medial epicondylitis can result from playing golf, American football, tennis and other racquet sports, archery, bowling, weightlifting, and javelin throwing. Pitchers and overhead throwing athletes often develop the disease because of high energy valgus forces during the late cocking and acceleration phase.
• In golfers, it is thought to occur from the top of the backswing to just before ball impact. However, more than 90% of cases are not sports-related. Labor intensive occupations with forceful, repetitive activities including professions in carpentry, plumbing, and construction are also implicated.

Epidemiology

• Medial epicondylitis, while less common than lateral epicondylitis, accounts for 10% to 20% of all epicondylitis.

• It is highest among subjects ages 45 to 64 and more common in women compared to men.

• Three out of four cases are in the dominant arm.

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Golfer's elbow

Signs and symptoms

• Patients will give a history of either an acute traumatic blow or repetitive elbow use, gripping, or valgus stress.
• They will report aching pain on the medial or ulnar side of the elbow, radiating from the epicondyle down into the forearm and wrist.
• It is often insidious, although acute injuries can occur.
• The pain is worse with forearm motion, gripping, or throwing.
• The pain resolves with cessation of activity.
• The patient may report elbow stiffness, weakness, numbness, or tingling most commonly in an ulnar nerve distribution.
• On exam, there may be swelling, Erythema, or warmth in acute cases; chronic cases are less likely to present with abnormalities on inspection. The patient will have tenderness over the five to ten millimetres distal and anterior to the medial epicondyle, especially near the conjoined tendon or muscles including pronator teres and flexor carpi radialis. Resisted Pronation or Flexion of the wrist elicits pain. The patient may be weak in the affected arm. The range of motion is typically normal.
• The golfer’s elbow test or medial epicondylitis test involves an active and a passive component. In the active component, the patient resists wrist flexion with the arm in extension and Supination. The passive component includes wrist extension with the elbow in extension. A test is positive when the patient endorses pain with this maneuver.

Diagnosis

• The diagnostic evaluation of medial epicondylitis is primarily clinical. Radiographs are usually normal and are most useful in ruling out other causes of elbow pain. In 20% to 30% of patients, they may demonstrate Periostitis or calcific tendinopathy.
• ultrasound is a quick, easy, and cost-effective modality to evaluate the muscle and tendon and help distinguish from other etiologies. It has a high sensitivity, specificity, and positive and negative predictive value for the diagnosis of medial epicondylitis.
• MRI (Magnetic resonance imaging) is the ideal standard for diagnosis of medial epicondylitis but generally is used to rule out other possible causes of medial elbow pain like ulnar collateral ligament strain or tear, Osteochondritis dissecans, or other soft tissue injuries.

Management

• Most cases of medial epicondylitis are managed non-surgically, although it is less common than lateral epicondylitis and more difficult to treat.
• Initial management should include cessation of offending activities including decreasing their volume, frequency, or intensity.
• Patients may respond to analgesia including non-steroidal anti-inflammatory drugs and acetaminophen. Opioids are not indicated. Ice can be helpful especially after activity. Topical nitroglycerin patches have proven helpful in treating tendinopathies.
• Physical therapy is the primary management modality for medial epicondylitis. The goal is full, painless motion at the wrist and elbow. Strength exercises should focus on eccentric activity. Multiple modalities may provide relief include dry needling, extracorporeal shock wave therapy and electrical stimulation, Iontophoresis. Soft tissue and manipulation techniques appear to allow more vigorous strengthening and stretching, resulting in better and faster recovery from the symptoms of medial epicondylitis.
• Night splinting with a cock up wrist splint may be helpful. A counterforce brace can unload the tendon, decreasing pain. Elbow taping with Kinesiology taping may also be useful.
• Ultrasound or palpation-guided corticosteroid injections can be used. Platelet-rich plasma injections have been shown to reduce pain and improve function in refractory epicondylitis.
• Surgical management is indicated in refractory cases but is usually not needed, with one study finding only 2.8% of patients requiring intervention. Surgical management includes the release of the common flexor tendon at the epicondyle and debridement of pathologic tissue. The mini-open muscle resection involves removal of degenerative tissue of the flexor carpis radialis. Fascial elevation and tendon origin resection (FETOR) is another available technique.

Differential diagnosis

• Neuropathy (such as C6 or C7 Radiculopathy, cubital tunnel syndrome, ulnar or median neuropathy, ulnar neuritis, anterior interosseous nerve entrapment)
• Ligamentous injury (such as ulnar or medial collateral ligament instability, sprain, or tear)
• Intra-articular issues like adhesive Capsulitis, arthrofibrosis, or loose bodies.
• Osseous concerns such as medial epicondyle avulsion fracture, or osteophytes.
• Tendinopathy (lateral epicondylitis, triceps tendonitis)

Prognosis

• The prognosis for medial epicondylitis is favorable. Most patients can return to work or sport after completing their physical therapy and activity modification.

Complications

• The most common complication of medial epicondylitis is persistent pain. Patients may develop an ulnar neuropathy, ulnar collateral ligament injury, or other associated conditions including carpal tunnel syndrome, lateral epicondylitis, or rotator cuff tendinitis. In cases managed surgically, complications include medial antebrachial cutaneous nerve neuropathy, ulnar nerve injury, or infection.

References

• John Kiel; Kimberly Kaiser. Golfer's elbow. [Updated June 29, 2020]. In StatPearls[Internet}. Available at: https://www.ncbi.nlm.nih.gov/books/NBK519000/
• Susan E. G. Sims, Katherine Miller, John C. Elfar, and Warren C. Hammert. 2014 May 8. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4235906/

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