Golfer's Elbow: Understanding, Causes, Symptoms, and Treatment

Why is it called golfers elbow?

Golfer's elbow, clinically known as medial epicondylitis, earns its name due to the common occurrence of this overuse injury in golfers, specifically stemming from the repetitive wrist flexion and forearm pronation movements inherent to the golf swing.

Understanding Golfer's Elbow: The Medical Perspective

Golfer's elbow is a form of tendinopathy characterized by pain and inflammation on the inner side of the elbow. While often referred to as "epicondylitis" (implying inflammation), current understanding suggests it's more accurately a "tendinosis," involving degenerative changes in the tendon collagen rather than just acute inflammation.

Anatomy Involved: The primary structures affected are the tendons of the forearm flexor-pronator muscles, which originate from a bony prominence on the inner side of the elbow called the medial epicondyle. These muscles include:

• Flexor Carpi Radialis: Flexes and abducts the wrist.
• Palmaris Longus: Flexes the wrist (variable presence).
• Flexor Carpi Ulnaris: Flexes and adducts the wrist.
• Flexor Digitorum Superficialis: Flexes the middle phalanges of the fingers.
• Pronator Teres: Pronates the forearm.

Repetitive stress on these tendons, particularly at their attachment point to the medial epicondyle, can lead to micro-tears, degeneration, and pain.

The "Golfer's" Connection

The name "golfer's elbow" directly links the condition to the biomechanics of the golf swing, where the forearm flexor-pronator muscles are heavily engaged.

Mechanism in Golf:

• Repetitive Wrist Flexion: During the downswing and follow-through, golfers powerfully flex their wrists, particularly the lead wrist (left wrist for a right-handed golfer), to generate clubhead speed and control impact. This action heavily loads the wrist flexor tendons.
• Forearm Pronation: The act of turning the palm downwards (pronation) is also a key component of the golf swing, especially in the follow-through, further stressing the pronator teres muscle and its tendon.
• Impact Forces: The forceful impact of the club with the ball or ground sends shockwaves up the arm, which the forearm muscles must absorb, adding to the cumulative stress.

Common Errors in Golf: Poor swing mechanics, such as casting the club, excessive wrist action, or hitting fat shots (hitting the ground before the ball), can significantly increase the load on the medial epicondyle, predisposing golfers to this injury. Additionally, using clubs that are too heavy or stiff, or playing too frequently without adequate rest, contribute to overuse.

Beyond the Golf Course: Other Causes and Activities

While golf is a prominent cause, medial epicondylitis is by no means exclusive to golfers. Any activity involving repetitive or forceful wrist flexion and forearm pronation can lead to the condition.

Occupational Risks: Individuals in professions requiring repetitive hand and wrist movements are at high risk, including:

• Carpenters
• Plumbers
• Electricians
• Assembly line workers
• Meat cutters

Sports Risks (Other than Golf):

• Baseball Pitching: Especially in throwing sports where the wrist is rapidly flexed and the forearm pronated during the throwing motion.
• Racquet Sports: Tennis (particularly with a topspin forehand), badminton, and squash, due to forceful wrist flexion.
• Bowling: The repetitive flicking motion of the wrist during release.
• Archery: The forces involved in drawing and releasing the bowstring.

Weight Training: Improper form or excessive loading during exercises that heavily involve the forearm flexors can also contribute:

• Bicep Curls: Especially with supinated grip and excessive wrist flexion.
• Pull-ups/Chin-ups: High grip demands can overload the flexor tendons.
• Rowing Exercises: Particularly if the grip is excessively tight or the wrist is hyperextended.

Symptoms and Diagnosis

Recognizing the symptoms of golfer's elbow is crucial for early intervention.

Pain Location and Characteristics:

• Inner Elbow: The primary symptom is pain and tenderness on the bony prominence on the inside of the elbow (medial epicondyle).
• Radiating Pain: The pain may radiate down the forearm towards the wrist, especially with gripping or twisting motions.
• Aggravating Activities: Pain worsens with activities like gripping objects, shaking hands, turning a doorknob, or flexing the wrist against resistance.

Associated Symptoms:

• Weakness: A noticeable decrease in grip strength.
• Stiffness: The elbow may feel stiff, especially in the morning.
• Numbness/Tingling: In some cases, the ulnar nerve, which passes close to the medial epicondyle, can become irritated, leading to numbness or tingling in the ring and little fingers.

Diagnosis: A healthcare professional typically diagnoses golfer's elbow through a physical examination. They will assess tenderness over the medial epicondyle and test for pain with specific movements like resisted wrist flexion and forearm pronation. Imaging, such as X-rays, is usually not necessary but may be used to rule out other conditions like fractures or arthritis. MRI may be considered in chronic or complex cases to assess tendon degeneration.

Prevention and Management Strategies

Effective management of golfer's elbow involves rest, pain relief, and targeted rehabilitation to strengthen and improve the flexibility of the affected tendons and muscles.

Prevention:

• Proper Technique: In sports or occupational tasks, learning and maintaining correct biomechanics is paramount. This includes proper grip, swing form, and lifting techniques.
• Gradual Progression: Avoid sudden increases in activity intensity or duration. Allow your body to adapt to new stresses.
• Strength and Flexibility: Regularly perform exercises that strengthen the forearm flexors and extensors, and stretch the wrist and forearm muscles to maintain flexibility.
• Ergonomics: Adjust workstations and tools to minimize repetitive strain.

Management (Non-Surgical):

• Rest: Avoid activities that aggravate the pain. This doesn't necessarily mean complete immobilization, but rather modifying or temporarily stopping the offending activity.
• Ice: Apply ice packs to the affected area for 15-20 minutes, several times a day, to help manage pain and any residual inflammation.
• Compression: An elbow brace or strap worn just below the elbow can help reduce tension on the affected tendons.
• Elevation: Elevating the arm can help reduce swelling.
• NSAIDs: Over-the-counter non-steroidal anti-inflammatory drugs (NSAIDs) like ibuprofen or naproxen can help manage pain.
• Physical Therapy: A physical therapist can provide a tailored exercise program focusing on:
  • Eccentric Strengthening: Exercises where the muscle lengthens under tension (e.g., slowly lowering a weight after a wrist curl) are particularly effective for tendinopathy.
  • Stretching: Gentle stretches for the wrist flexors and forearm.
  • Manual Therapy: Techniques to improve tissue mobility.
  • Activity Modification: Guidance on how to perform daily tasks or sports activities without aggravating the condition.
• Corticosteroid Injections: While offering temporary pain relief, these are generally used sparingly due to potential long-term negative effects on tendon health.
• Platelet-Rich Plasma (PRP) Injections: A newer treatment that involves injecting concentrated platelets from the patient's own blood to promote healing.
• Surgery: Rarely needed, surgery is considered only in severe, chronic cases that have not responded to extensive non-surgical treatment over 6-12 months. It involves removing damaged tendon tissue.

Conclusion

Golfer's elbow, or medial epicondylitis, is an overuse injury primarily affecting the tendons on the inner side of the elbow. Its name is a testament to the specific biomechanical stresses placed on these tendons during the golf swing, particularly the repetitive wrist flexion and forearm pronation. However, it's crucial to understand that this condition can affect anyone engaged in activities involving similar repetitive motions. Early recognition, proper management, and a focus on preventative measures such as correct technique and progressive training are key to recovery and preventing recurrence.