Golfer's Elbow

Play Golf? No? Well you don’t have to, in fact I don’t think that I have ever seen a sufferer of Golfer’s elbow who actually played golf! Actually, to get Golfer’s elbow as a golfer there must be a flaw in your technique. Amazingly tennis players who generate a lot of top spin on their forehand are a greater risk!

What is Golfer’s elbow?

Golfer’s elbow is an injury to the common flexor-pronator origin on the Humerus bone, more precisely the Pronator Teres and the Flexor Carpi Radialis origins (Nirshal 1993).

Golfer’s elbow is also known as pitchers elbow in the USA but the medical term has always been Medial Epicondylitis although as with all tendon pathologies this has been changed due to evidence on the inflammatory make up of tendon injury.  Immunohistological studies have shown that long-standing epicondylitis is associated with degeneration of the tissue instead of an inflammatory process (Ljung et al 1999).

So other names that have been touted things like Medial epicondylosis or Medial epicondylopathy and even Medial Epicondalgia.

How common is it?

Golfer’s elbow is nowhere near as common as Tennis elbow, which you can read about here: http://mathewhawkesphysiotherapy.blogspot.co.uk/2013/01/tennis-elbow.html?view=flipcard

Golfer’s elbow accounts for only 10-20% of epicondyle injuries (Plancher et al 1996).

But overall Medial Epicondylitis affects 0.3–0.6% of men and 0.3–1.1% of women and it is most common between the ages of 40-60 years of age (Shiri & Juntura 2011).

What causes it?

Basically it is an overuse injury characterised by angiofibroblastic tendinosis of the common flexor-pronator origin (Vinod & Ross 2015). Put simply this is cumulative overload of the tendon causing a build-up of microscopic tissue damage, which in turn causes various chemical and neurological effects in the local area and the central nervous system.

More specific reasons for the overload are below:

Poor technique:

Plancher et al (1996) found that poor throwing mechanics and technique can be a major cause of Golfer’s elbow. Tennis players that play with too much top spin, Golfers’ using the non-leading arm too much are other examples of poor technique risks.

Recovery time:

If you don’t allow enough recovery between loading activities then the tendon hasn’t got enough time to repair, and loading it again too soon will build cumulative damage. Tendons take a long time to recover and heal due to poor vascularisation (blood flow) (Nowak & Handyford 2000).

Fatigue:

When the muscle is fatigued the contraction strength is not as strong or fast, leading to more load or stretch being passed to the tendon. Exercise can disturb proprioception through fatigue, this has implications for musculoskeletal injuries (Proske & Gandevia 2012). Obviously when you fatigue your movement alters, which will change the way that your tendon is loaded.

Another specific reason is lack of flexibility:

If the Pronator Teres or the Flexor Carpi Radialis muscles are too short for the activity at hand then it is easier to potentially tear and if you don’t warm the tissue up before activity then the tissue is not as pliable making it tighter and more likely to damage.

Interestingly excessive flexibility is another factor:

Some people who are hypermobile (double jointed) or people who have over-lengthened their tendon are more likely to have problems as the tensile strength of the tendon is reduced, making it easier to overload.

Muscle and tendon weakness:

If the muscle isn’t strong enough and hasn’t been trained to take the loads of the sport (underload cause) then it can overload and tear.

Age:

Aging & Disuse contribute to a tendon's loss of resilience & strength (Nowak & Handyford 2000). And this is where loading (strength training) is even more important than ever to compensate for the loss of strength.

What are the symptoms?

Pain is very much over the medial epicondyle on the elbow, which is on the inside. Gripping is weak and painful along with lifting. Throwing will be affected in athletes and this may also be a cause. There is usually no swelling but it was found that proprioception was poorer in elbows with epicondylitis (Juul-Kristensen et al 2008), (This is like the spatial awareness of the elbow).

So how do you diagnose Golfer’s elbow?

An MRI is the most accurate way too make a diagnosis but you can perform an ultrasound scan to diagnose it too, which is cheaper and more accessible. An even quicker way to test for it is to look for pain and weakness on resisted pronation, which is also considered a reliable physical examination for golfer’s elbow (Vinod & Ross 2015).

However other issues can be present in this area too. For example it could be any of the following:

Cervical Radiculopathy

Ulnar Collateral Ligament Injury

Medial Epicondylar Apophysitis

Traction Aapophysitis

Medial Epicondylar fragmentation

How do you treat it?

The good thing is that conservative treatment is effective in 88-96% of cases (Gabel & Morrey 1995) but in 20-24% of cases the ulna nerve is affected too and this may need a surgical release (Vangsness & Jobe 1991).

If you have only just started to get symptoms then use “P.O.L.I.C.E.” within the first 48 - 72 hours:

P: Protect the injury from further harm: This can be stopping the activity, strapping it up, etc.

O.L: Optimal loading: This means load it but don’t overload it! This was put in place of rest because people were being too literal with rest and actually doing nothing, which is bad! So the key here is to move it, use it, etc. The key thing to remember is that as long as after doing the activity it is no worse for doing it, you are fine but if it is worse afterwards, then you have overloaded it.

I: Ice: This is to minimise the amount of excessive inflammation that gets to the injury site. You should wrap the ice in a damp tea towel and apply for 20 minutes.  The cooling effect should last for roughly 2 hours so you should re-apply it every 2 hours.

C: Compression: Now most people think that ice is the most important aspect but believe it or not it is actually compression. Compression helps control oedema formation & reduces swelling by promoting re-absorption (Knight 1995). Compression can take the form of tubi-grip or strapping and the aim is to create a back pressure that minimises the amount of swelling to the area. This is vital, as the more swelling you have, the more painful the injury will feel and the stiffer the area will become. It will inhibit muscle activity leading to muscle atrophy and it decreases proprioception. The other thing is that the more swelling there is, the longer it will take for your body to get rid of it.

E: Elevation: Basically keep the injury up as much as you can (in between your optimal loading etc.)

Now using P.O.L.I.C.E. for most cases won’t be needed as most of the time the injury will come on over a long period of time but if it comes on quickly after a major overload then this would be the time to use it.

Anti-Inflammatories:

Certainly not for chronic tendinosis and in tendinitis probably not either (jury’s out). See what the evidence says:

Ibuprofen inhibits tendon cell proliferation, therefore has a negative effect on tendon healing (Tsai et al 2004).

The Control group who didn’t take nonsteroidal anti-inflammatory drugs (NSAIDS) demonstrated progressively increasing collagen organization during the course of the study, whereas the NSAIDS group did not. This basically means NSAIDS where worse than doing nothing. (Cohen et al 2006).

The reason is that inflammation is needed to heal so we should have it and without it we can’t actually heal.

Activity management:

Basically reducing the overload to the area is a must to make a good recovery. Essentially if you continue to overload the structure then you can keep the injury symptomatic indefinitely. Absolute rest is not advised so the best option is to modify your activities to a level that doesn’t cause pain levels to increase. If you do an activity that is painful either during, after or the next day then this means that you are probably doing too much and you need to modify the activity so that it is tolerated. Amin et al (2015) found that activity management was very important in the management of Golfer’s elbow.

Ultrasound:

Ultrasound works best for: Ligament, Tendon, Fascia, Joint capsules & Scar tissue as they absorb it best (Sparrow et al 2005). Ultrasound doesn't have an anti inflammatory effect (Hashish 1988). Which is good! We need inflammation to heal & Ultrasound promotes it! So Ultrasound is good for both tendinitis and tendinosis.

Injections:

Autologous blood:

Injected locally to promote repair activity through the administration of growth factors directly to the site of injury (Coombes 2010).

However, there is no good quality evidence for autologous blood injections for chronic tendinopathy when compared to usual care (Rabago et al 2009).

Platelet-rich plasma:

Injected locally to promote repair activity through the administration of concentrated growth factors directly to the injury site (Coombes 2010).

However, there is insufficient evidence to support the use of Platelet Rich Therapies for musculoskeletal soft tissue injuries (Moraes et al 2013).

Aprotinin:

Injected locally to inhibit collagenase which would otherwise break down collagen and has been found to be increased in tendinopathy (Coombes 2010).

Polysulphated glycosaminoglycan:

Injected locally to prevent destruction and facilitate repair through inhibiting metalloproteinase enzyme activity (Coombes 2010).

Botulinum toxin:

Injected locally to decrease tensile stress through the tendon and inhibit substance P, which is increased in tendinopathy (Coombes 2010).

Sodium hyaluronate:

Injected locally to absorb mechanical stress and provide a protective buffer for tissues (Coombes 2010).

Corticosteroid:

Physio & placebo injection gave better results than steroid injections with elbow injuries in the short & long term (Coombes et al 2013).

Local steroid injection provides only short-term benefit in the treatment of medial epicondylitis (Golfer’s elbow) (Stahl & Kaufman 1997). Injected locally to down regulate (acting to decrease) inflammation in the affected tendon (Coombes 2010). Now with this injection you would definitely not want to do this with a tendinosis and there is reasoning that maybe it could be detrimental to the tendon in the long term whether it is tendinosis or tendinitis. This piece of research may not be on the Golfer’s elbow but Tennis elbow is also a tendinopathy in the elbow:

Corticosteroid injection versus placebo injection resulted in worse clinical outcomes after 1 year with Tennis elbow (Coombes et al 2013).

Polidocanol:

Targeted disruption of new vasculature by administration of a scelerosant to precipitate blood vessel fibrosis (Coombes 2010).

Prolotherapy:

Hypertonic glucose injected locally to initiate repair activity by causing local tissue trauma (Coombes 2010).

Strength training:

Evidence supports the belief that strength training decreases symptoms in tendinosis (Hoogvliet et al 2013).

Eccentric exercises:

Eccentric wrist flexor training has been shown to be effective in the management of Golfer’s elbow (Hudes 2011). They work on the basis of the fact that loading of tendon creates an upregulation of insulin-like growth factor (IGF-I) & this stimulates healing (Khan & Scott 2009).

Deep Transverse frictions:

There is insufficient evidence for deep transverse frictions with elbow tendinitis (Brosseau et al 2014) but there is excellent anecdotal evidence that fits the current understanding of tendinopathy.

Extracorporeal shock wave therapy:

This a considered a viable option for chronic cases and has been found as effective as a steroid injection but obviously without the detrimental effect of the steroid itself (Lee et al 2012).

Kinesio tape:

It many have some benefit but the benefit is no better than placebo taping (Chang et al 2012).

Epicondyle clasps:

An epicondylitis clasp/band is effective in reducing stress to the common extensor tendon in tennis elbow (Rothschild 2013) so it would make good sense that it too can help the other side of the elbow.

Surgery:

If after 3 to 6 months conservative management has failed, then surgery may be an option.

Flexor origin release and excision of the pathological tissue:

80% of patients report good outcomes from this technique. Potential complications include persistent ulnar nerve symptoms, and expected full return to sport usually occurs within 4-6 months (Plancher et al 1996).

Debridement with repair and restoration of the flexor-pronator origin, using a suture anchor:

The effectiveness of this technique was shown to be reliable and safe in restoring function and relieving pain when combined with aggressive rehabilitation (Vinod & Ross 2015).

Fascial elevation and tendon origin resection (FETOR):

This has been found to be an effective and safe method for treatment of this condition (Kwon et al 2014).

So as you can see Golfer’s elbow has many potential and effective treatments so if you think that you may have it then get in touch.

If you need any further information or would like to book an appointment then call Hawkes Physiotherapy on 01782 771861 or 07866195914

WWW.HAWKESPHYSIOTHERAPY.CO.UK