Golfer’s elbow (medial epicondylitis)
Golfer’s elbow is due to chronic degeneration of the tendon insertions on the inside of the elbow. It’s a painful condition caused by repetitive use and sprains of the tendons. Symptoms include pain and weakness when performing movements such as bending the wrist, making a fist or squeezing something in the hand. These are common movements in many sports and activities including golf, throwing and manual labour.
Golfer's Elbow Symptoms & Causes
Golfer’s elbow can be associated with compression of the ulnar nerve and in these cases abnormal sensation, tingling or burning might affect the ring and little fingers. Therefore, an ulnar nerve decompression may be required in addition to the standard surgical treatment.
Rarely golfer’s elbow can be associated with elbow instability, usually in throwing athletes, where the elbow feels unstable and may clunk on movement. Instability is caused by insufficiency of the ulnar collateral ligament on the inside of the elbow. This might also require surgical repair.
Diagnosis is usually confirmed by clinical examination. However an x-ray may be requested to exclude other causes of elbow pain. Often an ultrasound scan is performed if an acute tendon tear or calcium deposits within the tendon are suspected. Nerve conduction studies might be required if ulnar nerve compression is suspected. MRI can help diagnose elbow instability and tendon degeneration.
Golfer's Elbow Treatment
Approximately 90% of golfer’s elbow resolves without surgery. Recommended treatment often includes activity-modification, physiotherapy, injections or shockwave therapy.
Activity-modification and physiotherapy: This is usually the first line of treatment. Avoiding repetitive and painful movements or modifying activities to use other muscle groups will provide symptom relief. Physiotherapy exercises aim to combine stretching exercises with exercises to strengthen the flexor muscles. This is usually effective in the long-term. Splinting can be useful to reduce the strain on the insertion of the tendon on the bone.
Injections: Steroid can be injected locally into the affected area. This may provide short-term pain relief and is very helpful in acute phases. Up to three injections can be given. But, despite good short-term relief recent studies show no change of the disease or sometimes an even longer recovery time after steroid injections.
Shockwave therapy: A machine delivers sound waves into the affected area. Reported rates of success are extremely variable and therapy can sometimes be considered an experimental treatment but new evidence is coming out about its efficacy. However, whilst it is not possible to guarantee that it will work, it is very safe.
PRP injection: This is a new treatment used for some common orthopaedic conditions in your elbow like lateral epicondylitis (tennis elbow) or medial epicondylitis (golfer’s elbow).
Platelet rich plasma (PRP) is blood plasma with concentrated platelets (the body’s repair for damaged tissue). The concentrated platelets found in PRP contain growth factors that are vital to initiate and accelerate tissue repair and regeneration. These bioactive proteins initiate connective tissue healing and repair, promote development of new blood vessels, and stimulate the healing process.
The treatment involves obtaining a blood sample, centrifuging (spinning) it to retrieve the growth factors and reinject it in the tendon area, often under local anaesthesia.
Scientific evidence of this treatment is mild to moderate. There are no long-term studies but when it works this treatment may eliminate the need for more aggressive treatments such as long-term medication or surgery and a major advantage is the patient’s own growth factors are used rather than foreign substance is used as, and there are no risk of disease transmission.
Surgery: Surgery is usually performed as a day case and can be open or keyhole. Open surgery is usually very successful with more than 90% of patients improving significantly. Keyhole surgery is still new in this particular disease but it is showing promising results.
Rare complications of surgery include:
- nerve or blood vessel damage
- growth of islands of bone
- prolonged rehabilitation
- need for further surgery
Pain: During surgery local anaesthetic is injected around the wound and the elbow is numb for a few hours. After this you will be given painkillers to take whilst in hospital and at home. Ice packs may also help reduce pain. Ice can be wrapped in a damp tea towel and applied to the elbow for up to 20 minutes.
Wearing a sling: At the end of the operation you will be placed into a bandage dressing and a sling. These are for comfort and can be removed after 48 hours.
The wound: Keyhole surgery is usually performed through small 5-10mm wounds. With open surgery the wound will be a few centimetres in length. You may have dissolvable stitches or sticky strips over the wounds. You must keep the wounds dry and covered with a small dressing until they have healed. This usually takes 7-10 days.
Returning to work: This will depend on your job and your surgeon will advise you. You may be able to return to a desk job within a few days. However, manual labourers may need 8-12 weeks off work.
Driving: You will not be able to drive for about a week.
Leisure activities: You will not be allowed to lift anything heavy or do anything very active for approximately 6-12 weeks. Contact or high risk sports may need to be avoided for six months.
Follow-up appointment: You will be seen in outpatients by your surgeon two to three weeks after surgery.
Physiotherapy: Before you go home your physiotherapist will teach you some exercises for you to practise several times every day. You should continue these exercises until you see the physiotherapist in outpatients. Recovery time can be slow due to poor blood supply in the area and slow healing of the tendons. Whilst some improvement can be seen after four weeks, it often takes between four and six months to regain good/full function and strength with a pain-free elbow.