What is Golfer’s Elbow?
Medial epicondylalgia or ‘golfer’s elbow’ is an overuse injury involving the proximal flexor and pronator tendons in the anterior compartment of the forearm, all of which share an origin at the medial epicondyle of the humerus. The muscles involved may include pronator teres, and the long wrist/finger flexor muscles; flexor carpi radialis, palmaris longus, flexor digitorum superficialis, and flexor carpi ulnaris.
What causes Golfer’s Elbow?
Through repeated wrist/finger flexion and/or pronation, particularly when using an eccentric muscle action in a lengthened position, these tendons are stretched across the medial epicondyle and become damaged. This results in tendinopathic changes to the tendon’s structure and function, leading to increased tolerance to tensile loading.
Tendinopathies are considered to fall under one of three categories: reactive tendinopathy, tendon disrepair, and degenerative tendinopathy. In a reactive tendinopathy, the tendon’s cellular matrix thickens and stiffens as a temporary adaptation to excessive compressive or tensile loading. If not correctly rehabilitated this may lead to tendon disrepair, whereby collagen within the tendon becomes disordered, and its tolerance to load is further impaired. If left untreated, this may finally lead to degenerative tendinopathy where we see permanent impairments to tendon cellular structure and function.
Medial epicondylalgia is particularly common in manual workers and sportspeople using hand tools and equipment such as golfers (hence the name ‘golfer’s elbow’), tennis players performing a lot of topspin, bricklayers, or even office workers. Excessive or repeated elbow valgus maneuvers such as pitching in baseball also has the potential to compress and irritate the tendons of the medial epicondyle.
Differential Diagnosis
- Elbow MCL injury
- Ulnar/median nerve entrapment
- Flexor/pronator muscle strain (rather than a true tendinopathy)
- Osteoarthritis or other articular pathology
- Cervical radicular pain
- Referred pain from the shoulder
- 2nd to adhesive capsulitis, GIRD, or other shoulder pathology resulting in reduced external rotation
Common symptoms / signs
- History of suddenly increased or changed flexor/pronator use
- Common in golfers or tennis players using a lot of topspin
- Tenderness upon palpation over and distal to the medial epicondyle
- Pain with resisted wrist flexion +/- pronation
- Pain on stretch (elbow extension, forearm supination, wrist extension)
- Reduced ipsilateral shoulder external rotation
How is Golfer’s Elbow Treated?
Management should be similar to that of other tendinopathies, and follow the continuum of isometric exercise, to isotonic exercise, and eventually to energy storage and release activities. In the initial stages of acute management, we should aim to control pain, reduce the frequency and intensity of any aggravating activities, and address any relevant deficits further along the kinetic chain. Pain relief can be achieved through the use of isometric wrist flexion/pronation, which may also help to prevent flexor/pronator muscle atrophy through disuse. Manual therapy and ulnar nerve mobilisation may also be indicated to assist with pain relief at this stage. NSAIDs or other pharmacological strategies may be utilised for managing pain, but this should be overseen by the patient’s treating doctor. Aggravating activities should be modified or eliminated until pain is controlled (including technique or equipment modification for work or sporting activities). Other kinetic chain impairments which may be contributing to the issue should also be addressed here (such as inadequate shoulder external rotation in throwing athletes). Patient education regarding their condition, prognosis, and the need for progressive loading, should be continuously reinforced and begin from the first session.
Example exercises:
– isometric wrist flexion against desk 3×30”
– self-resisted isometric forearm pronation 3×30”
Once pain is settled, progressive isotonic loading of the flexors/pronators should begin in order to influence tendon architecture and improve that tendon’s capacity for load tolerance. This should include slow tempo (3:3 concentric/eccentric), heavy loading into wrist flexion/pronation, within a rep range of 10-20. This should be done daily, and should be modified so that next day pain does not exceed a 4/10 on the numerical pain scale. Excessive pain the next day may be indicative of continued abusive loading through an already irritated tendon, meaning exercise should be modified and loading reduced.
Example exercises:
– dumbbell wrist curls 3×15
– hammer pronation 3×15
The final phase of rehabilitation should involve a return to working/sporting activity, with activity-specific energy storage and release exercises implemented. This phase may also require further coaching or modification of technique/equipment in order to reduce the incidence of recurrence.
Example exercises:
– cable throwing technique work
Risk factors of Golfer’s Elbow
- Age (45-64 years)
- Female sex
- Smokers (current or ex)
- Physical occupation
- Use of hand tools (particularly vibrating tools)
- Reduced ipsilateral shoulder internal rotation
Other causes
- 2nd to repetitive elbow valgus
- Racket grip, technique
- Flexor/pronator weakness
References
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Brukner, P. (2017). Clinical sports medicine: Injuries. McGraw-Hill Education (Australia) Pty Limited.
Green, B., & Pizzari, T. (2017). Calf muscle strain injuries in sport: a systematic review of risk factors for injury. British journal of sports medicine, 51(16), 1189-1194.
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