Medial epicondylopathy: what is golfer’s elbow and how is it treated?

Braccio con mano spalancata e tesa

Medial epicondylopathy, also known as “Golfer’s Elbow”, is a painful condition which, in the majority of cases, affects people who are not involved in sports activities, or those who work as carpenters and plumbers…but not just them! In this article, we will investigate the causes, symptoms, and the stages of the treatment of medial epicondylopathy. Finally, don’t miss the physiotherapist’s 5 valuable tips for correctly managing this condition

  • What is Golfer’s Elbow?
  • Clinically Relevant Anatomy
  • Causes: who suffers most from medial epicondylopathy?
  • Pain mechanism
  • What are the symptoms of Medial Epicondylopathy?
  • How to treat Tennis Elbow
  • The Physiotherapist’s advice

What is Golfer’s Elbow?

Medial epicondylopathy, or “golfer’s elbow”, is mostly a tendinous overload injury leading to tendinopathy, i.e. tendon pain and discomfort. Flexor-pronator tendon degeneration occurs with repetitive forced wrist extension and forearm supination during activities involving wrist flexion and forearm pronation. Therefore, tendon degeneration appears instead of repair. The most sensitive region is located near the origin of the wrist flexors on the medial epicondyle of the humerus, and not to be confused with lateral epicondylopathy, better known as “tennis elbow”. In cases of medial epicondylopathy, the patient may occasionally experience pain on the ulnar side (inner) of the forearm, the wrist and, occasionally, in the fingers.

Clinically Relevant Anatomy

As mentioned above, golfer’s elbow affects the tendons of the flexor and pronator muscles of the forearm and wrist at the elbow. These muscles are:

–        Pronator Teres Muscle

–        Flexor Carpi Radialis Muscle

–        Palmaris Longus Muscle

–        Flexor Digitorum Superficialis Muscle

–        Flexor Carpi Ulnaris Muscle

All these muscles have the same origin on the medial epicondyle of the humerus (medial epicondyle). Most frequently the tendons affected are those of the flexor carpi radialis and pronator teres muscles.

Causes: who suffers most from medial epicondylopathy?

Medial epicondylar tendinopathy has a lower incidence than lateral epicondylopathy (tennis elbow). A staged process of pathologic change in the tendon can result in structural breakdown and irreparable fibrosis or calcification. Patients typically report persistent medial-sided (inner) elbow pain that is exacerbated by daily activities.

The pathology occurs in baseball pitchers or golfers as a result of high-energy valgus forces (inward movement of the elbow). It has also been reported with tennis, bowling, archery, weightlifting, javelin throwing, racquetball and American football. However 90 to 95% of all cases do not involve sportsmen. Because chronic repetitive concentric or eccentric contractile loading of the wrist flexors and pronator are the most common aetiology, occupations such as carpentry and plumbing have also been implicated. The pathology may also be produced by sudden violence to these tendons in a single traumatic event. In many cases trauma at work had been identified as the cause of the symptoms.

In the next section, we will explain the mechanism of pain linked to this particular form of “inflammation”.

Pain mechanism

Despite the name, it is more appropriate to call it Tendinopathy rather than Tendinitis.

In fact, most of the time, golfer’s elbow is not caused by inflammation. Rather, it is a problem within the cells of the tendon. In tendinopathy, wear and tear is thought to lead to tissue degeneration. A degenerated tendon usually has an abnormal arrangement of collagen fibres to which there may also be a greater prominence of cells and vascular spaces and focal necrosis or calcification.

When this happens, the collagen loses its strength. It becomes fragile and, in some instances, can break or be easily injured. Each time the collagen breaks down, the body responds by forming scar tissue in the tendon. Eventually, the tendon becomes thickened from extra scar tissue. The tendon changes from a white, glistening and firm surface to a dull appearing, slightly brown and soft surface.

What are the symptoms of Medial Epicondylopathy?

The patient usually complains about pain of the elbow distal, most common on the ulnar side (inner) of the forearm, the wrist and occasionally in the fingers.

Other characteristics are local tenderness (to the touch) over the medial epicondyle and the conjoined tendon of the flexor muscles, without evidence of swelling or erythema.

Other symptoms are:

– stiffness of the elbow

– weakness in the hand and the wrist

– a numb or tingling feeling in the fingers (mostly ring and little finger).

The pain is evoked by resisted flexion of the wrist and by pronation (rotation) of the forearm. The pain from medial epicondylopathy may occur suddenly or develop gradually over time.

How to treat Tennis Elbow

Once a diagnosis of medial epicondylopathy has been confirmed, a program of conservative physiotherapy normally follows.

The main goals are to relieve pain and reduce inflammation. Treatment can be divided into 3 phases:

–        Phase 1

The patient must first stop all activities which cause pain, while not stopping all sport/physical activity. Therefore, we must select a type of activity which does not cause pain.

In this phase we implement a protocol that includes rest, ice, and protection of the injured area. Physical therapies such as TECAR or LASER can be especially helpful, along with manual physical therapy. For athletes who cannot interrupt their activity, we often also recommend a compression brace at the elbow.

–        Phase 2

As soon as the symptoms begin to improve, a well guided rehabilitation can begin, in order to re-establish full, painless, wrist and elbow range of motion. Stretching protocols and isometric muscle contraction exercises of the upper limb muscles are then implemented, initially with the elbow flexed to avoid pain. Then, gradually, flexion of the elbow can be decreased until full extension is reached. As the symptoms continue to improve, we also introduce concentric and eccentric contractions of the forearm muscles.

–        Phase 3

This phase sees the patient return to sport or work activities. Therefore, the patient begins sport-specific or work-related exercises.

Other therapies that can help during rehabilitation are, for example, extracorporeal shock wave therapy or injections of corticosteroids or platelet rich plasma (PRP).

Surgery is rarely required.

The Physiotherapist’s advice

Finally, here are the physiotherapist’s 5 tips for correctly managing medial epicondylopathy:

  1. At the first sign of pain in the inner part of the elbow, stop and observe a period of rest from activities that create the symptoms.
  2. If you participate in sports or work activities (golf, weightlifting, baseball, electrician, etc.) which are linked to the disorder, you can help to prevent the problem through a daily routine of stretching the muscles of the upper limbs and neck (transverse muscle chain).
  3. If the pain does not subside with rest, request an assessment by physiotherapist specialised in sport/orthopaedic trauma injuries
  4. Always allow for an adequate recovery time following intense training so as not to overload the elbow area
  5. Sometimes the root of the elbow issue has a more distant cause: the physiotherapist should always investigate the cervical tract, the wrist, and the visceral/internal part.