How to treat golfer’s elbow

What is golfer’s elbow?

Golfer’s elbow, or medial epicondylitis, is the most common cause of medial (inside) elbow pain (7). The name medial epicondylitis, meaning an inflamed medial epicondyle (bony point on inside of elbow) can be labelled controversial due to the lack of inflammatory cells associated with the injury (7). 

Despite the name 90% of golfer’s elbow cases are not related to sport (3). Golfer’s elbow is currently believed to be caused by a chronic and repetitive use of the wrist flexors and pronators located in the forearm. A list of these muscles can be found on table 3. These muscles originate and attach to the medial epicondyle of humerus and due to this repetitive load, this bony point becomes sore (3). Labour intensive occupations that involve a forceful, repetitive action such as carpenters, plumbers and builders are often indicated (3).

Repetitive gripping, throwing, lifting or a combination of the three can cause changes within the mechanics of the tendon and therefore cause pain where the tendon inserts onto the bone. Sports associated with the injury include golf, baseball, cricket, rock climbing, basketball and weight-lifting (3). 

How common is golfer’s elbow?

Golfer’s elbow has been reported to affect 0.4% of the general population, highest between ages 45-64 and is more common in females than males (3). Interestingly, a different study that only included subjects in an occupational setting had a prevalence of 4-5% (2). Risk factors

1. In athletes
   1. Training errors
   2. Improper technique
   3. Equipment used 
2. Functional 
   1. Lack of strength
   2. Lack of endurance
   3. Lack of mobility
3. Occupational
   1. Heavy physical work
   2. Repetition 
4. General
   1. Smoking
   2. Obesity/high BMI
   3. Presence of comorbidities
   4. Psychological factors
   5. Age (over 40)

How do you diagnose golfer’s elbow?

In most cases, ME can be diagnosed clinically by a health professional such as a physiotherapist (7). A client with golfer’s elbow will likely report: 

1. Either trauma to the medial elbow, or a repetitive activity involving the elbow
2. Pain that is worsened by throwing, gripping or using the forearm
3. The pain usually resolves once the activity is ceased 
4. Approximately 20% of clients report ulnar nerve symptoms such as weakness, numbness or tingling on the inside of the forearm and pinky finger

Positive findings for golfer’s elbow include:

1. Tenderness over the medial epicondyle with potential redness/warmth if acute
2. Pain at this location during resisted wrist flexion of forearm pronation 
3. Reduced grip strength on the affected side 
4. Symptoms reproduced during the medial epicondylitis special test 
5. Diagnostic imaging (ultrasound and MRI)
   1. Can be less helpful/indicative
   2. Used to rule out other clinical entities

What causes golfer’s elbow?

Golfer’s elbow is a condition that is usually caused by repetitive throwing, twisting or lifting of the forearm/elbow. This repetition, if there is an error in technique or a lack of strength/capacity of the forearm muscles, can cause microtrauma and tears to the tendon and overtime can cause pain on the inside of the elbow. Golfer’s elbow often presents with no singular traumatic event with its source of pain believed to be a result of chronic fibroblastic proliferation, vascular hyperplasia and disorganised collagen rather than true inflammation (6).

What if it isn’t golfer’s elbow?

Health professionals must ensure an accurate diagnosis is given when treated a client with medial elbow pain. While golfer’s elbow is the most common type, it is important to rule out other diagnosis such as: 

1. C6/7 radiculopathy (i.e symptoms referring from neck)
2. Cubital tunnel syndrome
3. Ulnar or median neuropathy 
4. Ulnar neuritis
5. Anterior interosseous nerve entrapment
6. Ligamentous injury 
7. Arthritis 

Will my golfer’s elbow leave?

Prognosis for golfer’s elbow is favourable. Most clients with golfer’s elbow will have a full return to activities, work, sport or recreational pursuits – particularly if they were receiving help from a health professional and/or have been diligent with their acute management, rest and a progressive exercise program. 

So how do I treat golfer’s elbow?

Phase I: Settling the symptoms Following an acute golfer’s elbow, it is important to follow the RICE regime. Rest, Ice, Compress, Elevate. This regime will help reduce the stress placed on and around the medial epicondyle and allow a quicker recovery of the injured tissue – the quicker the elbow settles the sooner you can start loading and strengthening the elbow.  Cessation of the aggravating activities is important to allow the injured site to repair and for the potential swelling to subside – however this may be difficult for those with occupations requiring certain movements. For these scenarios, taping or bracing the elbow may be of benefit, icing after ward and/or anti-inflammatory medication from a doctor may help also.  Other things that can help reduce your pain: 

1. Massage to your elbow flexors 
2. A golfer’s elbow brace 
3. Topical nitroglycerin patches
4. Golfer’s elbow rocktape

Phase II: Rehabilitation through loading and strengthening  Tendon rehabilitation takes time, compliance and a progressive load (5). Unlike other injuries such as a muscle strain or mild disc irritation in the back – tendon’s take 12 weeks of progressive loading to change from being pathological and painful to functioning normally (5). Throughout this process, there are lots of modalities to use to reduce the pain associated with golfer’s elbow – and can be seen in the graph below. This graph also shows that as time goes on and pain improves, you may experience an increase in pain. This is called a flare-up and its important not to think you are back to square one, settle the symptoms down and continue with your progressive exercises. 

The most important ingredient in the recipe of managing golfer’s elbow and similar to tennis elbow – is a progressive loading program. Due to the condition being a tendinopathy, and not an acute tear, the only way to return the injured tendon to normal function is through applying a load to it and progressing it as pain and strength allows.  There are a few exercises that have been proven to be an effective way of applying a safe, progressive load to the common wrist flexor tendon. These include:

1. Eccentric exercise  Eccentric exercise has been proven to benefit conditions such as Achilles and patellar tendinopathies – golfer’s elbow is no different. In a 2011 study, eccentric exercise starting with a 1kg weight and progressing the weight by 10% each week for 12 weeks showed a significant reduction in pain and grip strength in the affected arm (7).

2. Forearm twists Unlike tennis elbow, golfer’s elbow involves the muscles that rotate the forearm downward (pronation). Therefore, when applying a loading program to a golfer’s elbow – both wrist flexion and forearm pronation should be included. See the video below for a demonstration. Initially, you can start with a water bottle or tin/can and progress your weight via reducing the grip size, increasing the weight or increasing the length of the object you’re rotating with your forearm. 

3. Tyler twist  In 2013, a study looked at the effect of the “Tyler Twist” on subjects with a diagnosis of golfer’s elbow. They performed the exercise for 3 sets and 15 reps with 60 seconds between each set (5). They did this twice a day for 5 days of the week. Results showed a 77% improvement of DASH scores after the 6 week trial (5). 

 

Phase III: Return to your sport or activity 

During the final phase of rehabilitating your golfer’s elbow – it is important to put the elbow through exercises that will target its ability to store energy and release it (8). This is done via fast, explosive exercises also known as “plyometric” training. This type of training for golfer’s elbow can be as simple as hitting a ball against a wall with your palm or playing handball. 

 

What are some other treatments for Golfer’s Elbow?

Medication Primarily used for pain control, medications such as non-steroidal anti-inflammatory drugs (NSAIDs) are commonly used however due to the lack of inflammatory markers in golfer’s elbow – remain controversial (6). A short course may be indicated to increase comfort for clients when performing the prescribed exercises (6). 

Corticosteroid injection  Although golfer’s elbow isn’t an inflammatory disease, it does show to have increased neurogenic pain markers which corticosteroid injections have been documented to relieve neurogenic pain symptoms (6). A 2009 study demonstrated the short term pain benefits of CSI for epicondylitis (up to 8 weeks) and was supported in 2013 with a meta-analysis showing that CSI are more effective at short-term pain relief than placebo 

Autogous blood and platelet-rich plasma (PRP) injections The results from these types of injections have been promising but inconsistent (6). They can be performed with or without ultrasound guidance and are though to use angiogenic mediators to aid in the healing response by recruiting vascularity to the damaged tissue (6). There is research supporting the use of PRP injections over bupivacine and placebo treatments however a meta-analysis has shown that these studies are likely to have bias favouring the procedure.  A study involving 20 subjects with a 12+ month history of golfer’s elbow underwent rigorous dry needling into the tendon to cause local bleeding before autologous blood injection and achieved favourable results (6). 

Extracorporeal Shockwave Therapy (ESWT) It is believed that ESWT may provide pain relief for some clients with golfer’s elbow (9). A study involving newly diagnosed clients were treated with ESWT or steroid injection and showed that while pain scores at 1-2 weeks were worse in the ESWT group, they had better satisfaction at the 8 week follow-up. However, interestingly a study showed that only 7 of 30 clients had excellent-good clinical results at the 1-year follow up (9). This, when compared to the tennis elbow group, was notably worse despite undergoing similar treatment (9). 

For more information on Extracorporeal Shockwave Therapy (ESWT) see my blog HERE >>> 

For more information on Tennis Elbow see my blogs: Part 1 HERE >>> and Part 2 HERE >>>     

Alec Lablache

POGO Physiotherapist

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References

1. Chang, H., Cheng, S., Lin, C., Chou, K., Gan, S., & Wang, C. (2013). The effectiveness of kinesio taping for athletes with medial elbow epicondylar tendinopathy. International Journal of Sports Medicine, 34(11), 1003-1006. doi:10.1055/s-0033-1333747
2. Descatha, A., Leclerc, A., Chastang, J. F., Roquelaure, Y., & Study Group on Repetitive Work. (2003). Medial epicondylitis in occupational settings: Prevalence, incidence and associated risk factors. Journal of Occupational and Environmental Medicine, 45(9), 993-1001. doi:10.1097/01.jom.0000085888.37273.d9 
3. Kiel J., Kaiser K. (2019). Golfers Elbow. StatPearls Publishing, n.d, n.d. Retrieved from: https://www.ncbi.nlm.nih.gov/books/NBK519000/
4. McMurtrie, A., & Watts, A. C. (2012). (vi) tennis elbow and golfer’s elbow. Orthopaedics and Trauma, 26(5), 337-344. doi:10.1016/j.mporth.2012.09.001 (VI)
5. New exercise effective for golfer’s elbow: Exercise treatment significantly reduced pain after other conservative treatments failed. (2014). PR Newswire Retrieved from https://search-proquest-com.elibrary.jcu.edu.au/docview/1552846432?accountid=16285
6. Pitzer, M. E., MD, Seidenberg, P. H., MD, & Bader, D. A., MD. (2014). Elbow tendinopathy. Medical Clinics of North America, 98(4), 833-849. doi:10.1016/j.mcna.2014.04.002 
7. Svernlöv, B., Hultgren, E., Adolfsson, L. (2012). Medial epicondylalgia (golfer’s elbow) treated by eccentric exercise. Shoulder & Elbow, 4(1), 50-55. doi:10.1111/j.1758-5740.2011.00152.x
8. Malliaras, P., Barton, C. J., Reeves, N. D., & Langberg, H. (2013). Achilles and patellar tendinopathy loading programmes: A systematic review comparing clinical outcomes and identifying potential mechanisms for effectiveness. Sports Medicine, 43(4), 267-286. doi:10.1007/s40279-013-0019-z
9. Lee, S. S., Kang, S., Park, N. K., Lee, C. W., Song, H. S., Sohn, M. K., . . . Kim, J. H. (2012). Effectiveness of initial extracorporeal shock wave therapy on the newly diagnosed lateral or medial epicondylitis. Annals of Rehabilitation Medicine, 36(5), 681-687. doi:10.5535/arm.2012.36.5.681