Golfer’s Elbow (Medial Epicondylitis)

Gary Loss
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History and Epidemiology

Medial epicondylitis (ME), also known as Golfer’s elbow, is caused by damage to the muscles and tendons that control the wrist and fingers. The damage is typically related to excess or repeated stress — especially forceful wrist and finger motions. Although golfer’s elbow involves pathologic alterations in the musculotendinous origins at the medial epicondyle and is associated with injuries sustained by swinging golf clubs, the condition is often caused by a variety of sports as well as occupational activities.1 Some sources indicate that ME is commonly seen among people who engage in regular physically demanding work and may be worsened by poor body mechanics, improper techniques, and/or inadequate equipment or tools to perform work tasks.2

There is ongoing debate about the prevalence of golfer’s elbow as well as the causes of the condition among subpopulations. While some studies indicated an overall prevalence of less than 1% for ME in the general population, and a prevalence ranging from 3.8% to 8.2% for patients in occupational settings that require over- or forceful use of the forearm, 3, 4  other studies show there is insufficient evidence of a causal link between occupational exposure to biomechanical risk factors inherent in some occupations and resultant medial elbow tendinopathy.5 Still, other researchers found that the incidence of MEs increased significantly between 2007 and 2014, with older patients seeking surgical options more often than younger counterparts.6 The lack of clarity around these contradictory findings highlights the need for further well-designed, controlled, robust research.

Golfer’s Elbow Diagnosis & Presentation

Patients with golfer’s elbow present with tenderness distal to the medial epicondyle and referred pain with activities that place stress on the origin of these muscles, such as golf, tennis, weight-lifting, swimming, and work-related activities.7 The examination will reveal tenderness along the medial epicondyle, proximal pronator, and flexor tendons, with pain associated with resisted wrist flexion and pronation as well as passive terminal wrist extension, all with the elbow fully extended.8 A thorough history should be taken in addition to palpation and movement testing. Elbow pain is typically exacerbated by activity and is particularly problematic during the late cocking phase in overhead throwing movements and may be precipitated by an acute, traumatic blow to the elbow, though more commonly, the pain is characterized by a gradual onset that does not respond to rest.9

Differential Diagnosis

The differential diagnosis of medial epicondylitis should consider multiple neuropathic conditions, such as radiculopathy, cubital tunnel syndrome, ulnar or median neuropathy, ulnar neuritis, anterior interosseous nerve entrapment, or tardy ulnar nerve palsy. Clinicians should also rule out ligamentous injury, such as ulnar or medial collateral ligament instability, sprains, or tears, intra-articular issues, including adhesive capsulitis, arthrofibrosis, or loose bodies; osseous concerns, such as medial epicondyle avulsion fracture, or osteophytes myofascial difficulties, such as flexor or pronator strains, as well as conditions like synovitis and valgus extension overload (pitcher’s elbow). Moreover, dermatologic concerns, such as herpes zoster, should also be eliminated as causative or contributing factors.3 It is also important to rule out cubital tunnel syndrome by using the ulnar nerve examination flexion test, which consists of full elbow flexion with full extension of the wrists for three minutes, with patients reporting symptoms of pain, numbness, or tingling.10

Clinicians should distinguish golfer’s elbow from lateral epicondylitis (LE), more commonly known as tennis elbow. In LE, exacerbation of pain is caused by resisted wrist dorsiflexion and forearm supination, while golfer’s elbow is elicited with resisted wrist flexion and pronation.11 Research also suggests that muscle function and pain measures showed a lesser impaired function of the arm in chronic golfer’s elbow than chronic LE.12

Imaging may be necessary to make an accurate diagnosis. Radiologic images may help reveal arthritic components and calcifications associated with tendinous pain. A recent review found that although most radiologic findings of golfer’s elbow are normal, up to 25% show calcifications, and these calcifications were associated with higher reported pain scores, a history of steroid injection, and combined ulnar neuropathy, with age being strongly associated with broad distribution of calcification.13

Magnetic resonance arthrography of the elbow is helpful to evaluate intra-articular loose bodies, osteochondral and chondral lesions, capsular and ligamentous injuries, medial elbow pain, and elbow dislocations.14  Ultrasound examination can serve as a complementary diagnostic tool for an orthopedic specialist, and allows for the assessment of both the medial epicondyle and adjacent structures, including the ulnar nerve, muscles, and their attachments, all of which supports a reliable differentiated diagnosis.15

Golfer’s Elbow Management
(Nonpharmocotherapy and Pharmacotherapy)

As with most tendinopathies, non-surgical, conservative treatment is the first line approach to resolving golfer’s elbow. For acute cases of golfer’s elbow, patients should refrain from activities that instigate or exacerbate symptoms, especially those that require repetitive wrist flexion and forearm pronation.9 Topical and oral non-steroidal anti-inflammatory drugs (NSAIDs) may provide short-term pain relief and increases range of motion, which can assist patients in completing rehabilitative exercises.16

Physical therapy (PT) can reduce pain and increase flexibility, and should focus on establishing full, painless wrist and elbow range of motion, followed by stretching and progressive isometric exercises.2 For athletes, core and lower body strengthening may also aid in throwing mechanics and complete reconditioning of the upper limb to maintain tendon excursion and strength during rigorous tendon stress is central to preventing further injuries.9  While corticosteroid injections are routinely used to alleviate acute pain, most investigations that report long-term outcomes demonstrate no advantage to the use of corticosteroid for golfer’s elbow.17

Compared to lateral epicondylitis (LE), there is a lack of literature about the use of straps as a rehabilitative measure of golfer’s elbow. Extracorporeal shock-wave therapy (ESWT), which involves inducing microtrauma to the affected area using repeated shock waves to stimulate neovascularization and healing, has also become popular for treating tendon injuries. There is significant anecdotal evidence that ESWT is efficacious in treating tendonitis and tendinosis; however, multiple controlled studies have yielded mixed results. While several studies have found that ESWT is no more effective than placebo,18, 19 other studies have concluded that ESTW is effective for people with chronic LEs. 20, 21 Further investigation is needed to test this approach for people with MEs. Surgery to repair golfer’s elbow should be utilized only when all other conservative options have failed to give relief of pain and discomfort.1

Monitoring Side Effects, Adverse Events, Drug-Drug Interactions

NSAIDs should be used as a short- to mid-term approach for pain management in the setting of ME. However, long-term use of NSAIDs may increase risks for gastrointestinal, renal, and cardiovascular complications.22 Although corticosteroid injections tend to be safe and efficacious in the short-term, prolonged or overuse of corticosteroid injections can also lead to adverse outcomes, including accelerated osteoarthritis progression, subchondral insufficiency fracture, complications of osteonecrosis, and rapid joint destruction with bone loss.23

References

  1. Ciccotti, MG; Ramani, MN. Medial epicondylitis. Sports Medicine and Arthroscopy Review. March 2003; 11(1):57-62.  
  2. Reece CL, Susmarski A. Medial epicondylitis. In: StatPearls. NCBI Bookshelf version. StatPearls Publishing; 2022. Accessed September 21, 2022.
  3. Kiel J, Kaiser K. Golfers elbow. In: StatPearls. NCBI Bookshelf version. StatPearls Publishing; 2022. Accessed September 21, 2022.
  4. Descatha A, Leclerc A, Chastang JF, Roquelaure Y; Study Group on Repetitive Work. Medial epicondylitis in occupational settings: prevalence, incidence and associated risk factors. J Occup Environ Med. 2003 Sep;45(9):993-1001. doi:10.1097/01.jom.0000085888.37273.d9
  5. Curti S, Mattioli S, Bonfiglioli R, Farioli A, Violante FS. Elbow tendinopathy and occupational biomechanical overload: A systematic review with best-evidence synthesis. J Occup Health. 2021 Jan;63(1):e12186. doi:10.1002/1348-9585.12186
  6. Wiggins AJ, Cancienne JM, Camp CL, et al. Disease Burden of Medial Epicondylitis in the USA is Increasing: An Analysis of 19, 856 Patients from 2007 to 2014. HSS Journal. 2018;14(3):233-237. doi:10.1007/s11420-018-9617-5 
  7. 7.Barco, R, and Antuña, SA. Medial elbow pain. EFORT Open Reviews 2.8 (2017):362-371. https://doi.org/10.1302/2058-5241.2.160006
  8. Zahn K, Byerly D. Medial epicondyle injection. National Library of Medicine. Published June 5, 2022. Accessed September 21, 2022.
  9. Amin NH, Kumar NS, Schickendantz MS. Medial epicondylitis: evaluation and management. J Am Acad Orthop Surg. 2015 Jun;23(6):348-55. doi:10.5435/JAAOS-D-14-00145 PMID: 26001427.
  10. Buehler MJ, Thayer DT. The elbow flexion test. A clinical test for the cubital tunnel syndrome. Clin Orthop Relat Res. 1988 Aug;(233):213-216. PMID: 3402126.
  11. Miller R, Azar F, Throckmorton T. Shoulder and Elbow Injuries. Int Orthop. 2011; 35(6): 851-860.
  12. Pienimäki TT, Siira PT, Vanharanta H. Chronic medial and lateral epicondylitis: a comparison of pain, disability, and function. Arch Phys Med Rehabil. 2002 Mar;83(3):317-321. doi:10.1053/apmr.2002.29620 PMID: 11887110.
  13. Kang KB, Cheon SH, Lee HD. Radiologic evaluation and clinical effect of calcification in medial epicondylitis. J Shoulder Elbow Surg. 2022 Feb;31(2):375-381. doi:10.1016/j.jse.2021.08.031 PMID: 34610463.
  14. Acosta Batlle J, Cerezal L, Márquez MV, López Parra MD, Soteras C, Resano S, Sánchez JB. MRI of the Normal Elbow and Common Pathologic Conditions. Radiographics. 2020 Mar-Apr;40(2):468-469. doi:10.1148/rg.2020190134 PMID: 32125957.
  15. Konarski W, Poboży T, Kotela A, Hordowicz M, Poboży K. Ultrasound in the Differential Diagnosis of Medial Epicondylalgia and Medial Elbow Pain-Imaging Findings and Narrative Literature Review. Healthcare (Basel). 2022 Aug 13;10(8):1529. doi:10.3390/healthcare10081529 PMID: 36011187; PMCID: PMC9407887.
  16. Kane SF, Olewinski LH, Tamminga KS. Management of Chronic Tendon Injuries. Am Fam Physician. 2019 Aug 1;100(3):147-157. PMID: 31361101.
  17. Bradley J, Fotios  T, Kreines A, Austin L. Elbow Injuries in Pediatric and Adolescent Athletes. DeLee, Drez, & Miller’s Orthopaedic Sports Medicine, 5th edition. Philadelphia: Elsevier, 2020. Accessed September 21, 2022.
  18. Speed CA, Nichols D, Richards C, et al. Extracorporeal shock wave therapy for lateral epicondylitis–a double blind randomised controlled trial. J Orthop Res. 2002;20(5):895-898. doi:10.1016/S0736-0266(02)00013-X
  19. Haake M, König IR, Decker T, et al. Extracorporeal shock wave therapy in the treatment of lateral epicondylitis : a randomized multicenter trial. J Bone Joint Surg Am 2002 Nov;84(11):1982-91. doi:10.2106/00004623-200211000-00012
  20. Bayram K, Yesil H, Dogan E. Efficacy of extracorporeal shock wave therapy in the treatment of lateral epicondylitis. North Clin Istanb. 2014;1(1):33-38. Published 2014 Aug 3. doi:10.14744/nci.2014.77487
  21. Yao G, Chen J, Duan Y, Chen X. Efficacy of Extracorporeal Shock Wave Therapy for Lateral Epicondylitis: A Systematic Review and Meta-Analysis. Biomed Res Int.
  22. Crofford LJ. Use of NSAIDs in treating patients with arthritis. Arthritis Res Ther. 2013;15 Suppl 3 (Suppl 3):S2. doi:10.1186/ar4174
  23. Kompel AJ, Roemer FW, Murakami AM, Diaz LE, Crema MD, Guermazi A. Intra-articular Corticosteroid Injections in the Hip and Knee: Perhaps Not as Safe as We Thought? Radiology. 2019;293(3):656-663. doi:10.1148/radiol.2019190341

Author Bio

Gary Loss, formerly a public education consultant, is a diverse writer with experience in the education and health sectors.

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