A Patient's Guide to Medial Epicondylitis (Golfer's
Elbow)
Introduction
Medial epicondylitis is commonly known as
golfer's elbow. This does not mean that only
golfers have this condition. But the golf swing is a
common cause of medial epicondylitis. Many other
repetitive activities can also lead to golfer's elbow:
throwing, chopping wood with an ax, running a chain
saw, and using many types of hand tools. Any
activities that stress the same forearm muscles can
cause symptoms of golfer's elbow.
This guide will help you understand
- what parts of the elbow are affected
- what causes golfer's elbow
- how to make the pain go away
Anatomy
What parts of the elbow are affected?
Golfer's elbow causes pain that starts on the
inside bump of the elbow, the medial
epicondyle. Wrist flexors are the muscles
of the forearm that pull the hand forward. The wrist
flexors are on the palm side of the forearm. Most of
the wrist flexors attach to one main tendon on
the medial
epicondyle. This tendon is called the common
flexor tendon.
Tendons connect muscle to bone. Tendons are made up
of strands of a material called collagen.
The collagen strands are lined up in bundles next to
each other.
Because the collagen strands in tendons are lined
up, tendons have high tensile strength. This
means they can withstand high forces that pull against
both ends of the tendon. When muscles work, they pull
on one end of the tendon. The other end of the tendon
pulls on the bone, causing the bone to move.
The wrist flexor muscles contract when you flex
your wrist, twist your forearm down, or grip with your
hand. The contracting muscles pull on the flexor
tendon. The forces that pull on the tendon can build
when you grip a golf club during a golf swing or do
other similar actions.
Related Document: A
Patient's Guide to Elbow Anatomy
Causes
Why did I develop golfer's elbow?
Overuse of the muscles and tendons of the forearm
and elbow are the most common reason people develop
golfer's elbow. Repeating some types of activities
over and over again can put too much strain on the
elbow tendons. These activities are not necessarily
high-level sports competition. Shoveling, gardening,
and hammering nails can all cause the pain of golfer's
elbow. Swimmers who try to pick up speed by powering
their arm through the water can also strain the flexor
tendon at the elbow.
In some cases, the symptoms of golfer's elbow are
due to inflammation. In an acute injury, the body
undergoes an inflammatory response. Special
inflammatory cells make their way to the injured
tissues to help them heal. Conditions that involve
inflammation are indicated by -itis on the end
of the word. For example, inflammation in a tendon is
called tendonitis. Inflammation around the
medial epicondyle is called medial
epicondylitis.
However, golfer's elbow often is not caused by
inflammation. Rather, it is a problem within the cells
of the tendon. Doctors call this condition
tendonosis. In tendonosis, wear and tear is
thought to lead to tissue degeneration. A degenerated
tendon usually has an abnormal
arrangement of collagen fibers.
Instead of inflammatory cells, the body produces a
type of cells called fibroblasts. When this
happens, the collagen loses its strength. It becomes
fragile and 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.
No one really knows exactly what causes tendonosis.
Some doctors think that the forearm tendon develops
small tears with too much activity. The tears try to
heal, but constant strain and overuse keep re-injuring
the tendon. After a while, the tendons stop trying to
heal. The scar
tissue never has a chance to fully heal, leaving
the injured areas weakened and painful.
Symptoms
What does golfer's elbow feel like?
The main symptom of golfer's elbow is tenderness
and pain at the medial epicondyle of the elbow. Pain
usually starts at the medial epicondyle and may spread
down the forearm. Bending your wrist, twisting your
forearm down, or grasping objects can make the pain
worse. You may feel less strength when grasping items
or squeezing your hand into a fist.
![](C:\ChiroOrg\LINKS\FULL\Medial_Epicondylitis_files\mypic(1).jpg)
Diagnosis
How can my doctor be sure I have golfer's
elbow?
Your doctor will first take a detailed medical
history. You will need to answer questions about your
pain, how your pain affects you, your regular
activities, and past injuries to your elbow.
The physical exam is often most helpful in
diagnosing golfer's elbow. Your doctor may position
your wrist and arm so you feel a stretch on the
forearm muscles and tendons. This is usually painful
with golfer's elbow. Other tests for wrist and forearm
strength are used to help your doctor diagnose
golfer's elbow.
You may need to get X-rays of your elbow. The
X-rays mostly help your doctor rule out other problems
with the elbow joint. The X-ray may show if there are
calcium deposits on the medial epicondyle at the
connection to the flexor tendon.
Golfer's elbow symptoms are very similar to a
condition called cubital tunnel syndrome. This
condition is caused by a pinched ulnar nerve as
it crosses the elbow on its way to the hand. If your
pain does not respond to treatments for golfer's
elbow, your doctor may suggest tests to rule out
problems with the ulnar nerve.
Related Document: A
Patient's Guide to Cubital Tunnel Syndrome
When the diagnosis is not clear, the doctor may
order other special tests, such as a magnetic
resonance imaging (MRI) scan or ultrasound.
An MRI scan uses magnetic waves to create pictures of
the elbow in slices. The MRI scan shows tendons as
well as bones.
Ultrasound tests use high-frequency sound waves to
generate an image of the tissues below the skin. As
the small ultrasound device is rubbed over the sore
area, an image appears on a screen. This type of test
can sometimes show collagen
degeneration.
Treatment
How can I make my pain go away?
Nonsurgical Treatment
The key to nonsurgical treatment is to keep the
collagen from breaking down further. The goal is to
help the tendon heal.
If the problem is caused by inflammation,
anti-inflammatory medications such as ibuprofen may
give you some relief. If inflammation doesn't go away,
your doctor may inject the elbow with
cortisone. Cortisone is a powerful
anti-inflammatory medication. Its benefits are
temporary, but they can last for a period of weeks to
several months.
Shock wave therapy is a newer form of
nonsurgical treatment. It uses a machine to generate
shock wave pulses to the sore area. Patients generally
receive the treatment once each week for up to three
weeks. It is not known exactly why it works for
golfer's elbow, but recent studies indicate that this
form of treatment can help ease pain, while improving
range of motion and function.
Doctors commonly have their patients with golfer's
elbow work with a physical or occupational therapist.
At first, your therapist will give you tips on how to
rest your elbow and how to do your activities without
putting extra strain on your elbow. Your therapist may
apply tape to take some of the load off the elbow
muscles and tendons. You may use an elbow strap that
wraps around the upper forearm in a way that relieves
the pressure on the tendon attachment.
Your therapist may apply ice and electrical
stimulation to ease pain and improve healing of the
collagen. Therapy sessions may also include
iontophoresis, which uses a mild electrical
current to push anti-inflammatory medicine to the sore
area. This treatment is especially helpful for
patients who can't tolerate injections. Exercises are
used to gradually stretch and strengthen the forearm
muscles.
Because tendonosis is often linked to overuse, your
therapist will work with you to reduce repeated
strains during activity. When symptoms are from a
particular sport or work activity, your therapist will
observe your style and motion with the activity. Your
therapist may suggest ways to protect the elbow during
your activities. Your therapist can also check your
sports equipment and work tools and recommend ways to
alter them to keep your elbow safe.
Surgery
Sometimes nonsurgical treatment fails to stop the
pain or help patients regain use of the elbow. In
these cases, surgery may be necessary. Tendon
Debridement
When problems are caused by tendonosis, surgeons
may choose to take out (debride) only the
affected tissues within the tendon. In these cases,
the surgeon cleans up the tendon, removing only the
damaged tissue. Tendon Release
A commonly used surgery for golfer's elbow is
called a medial epicondyle release. This
surgery takes tension off the flexor tendon. The
surgeon begins by making an incision along the arm
over the medial epicondyle. Soft tissues are gently
moved aside so the surgeon can see the point where the
flexor tendon attaches to the medial epicondyle.
The flexor tendon is then cut where it connects to
the medial epicondyle. The surgeon splits the tendon
and takes out any extra scar tissue. Any bone
spurs found on the medial epicondyle are removed.
(Bone spurs are pointed bumps that can grow on the
surface of the bones.) Some surgeons suture the loose
end of the tendon to the nearby fascia tissue.
(Fascia tissue covers the muscles and organs
throughout your body.) The following images show
each step
View
animation of the procedure
Your surgeon will look at the ulnar nerve, to make
sure that it is not being pinched. If the nerve looks
fine, the skin is then stitched together.
This surgery can usually be done on an outpatient
basis, which means that you don't have to stay
overnight in the hospital. It can be done using a
general anesthetic or a regional
anesthetic. A general anesthetic puts you to
sleep. A regional anesthetic blocks only certain
nerves for several hours. For surgery on the elbow,
you would most likely get an axillary block to
numb your arm.
Rehabilitation
How soon can I use my elbow again?
Nonsurgical Rehabilitation
In cases where the tendon is inflamed, nonsurgical
treatment is usually only needed for four to six
weeks. When symptoms are from tendonosis, you can
expect healing to take longer, usually up to three
months. If the tendonosis is chronic and severe,
complete healing can take up to six months.
After Surgery
Recovery from surgery takes longer. Immediately
after surgery, your elbow is placed in a removable
splint that keeps your elbow bent at a 90-degree
angle. Ice and electrical stimulation treatments may
be used during your first few therapy sessions to help
control pain and swelling from the surgery. Your
therapist may also use massage and other types of
hands-on treatments to ease muscle spasm and pain.
You will gradually work into more active stretching
and strengthening exercises. You just need to be
careful to avoid doing too much, too quickly. Active
therapy starts about two weeks after surgery. Your
therapist may begin with light isometric
strengthening exercises. These exercises work the
muscles of the forearm without straining the healing
tissues. You will use your own muscle power in active
range-of-motion exercises.
At about six weeks, you start doing more active
strengthening. As you progress, your therapist will
give you exercises to help strengthen and stabilize
the muscles and joints of the wrist, elbow, and
shoulder. You'll also do exercises to improve fine
motor control and dexterity of the hand. Some of the
exercises you'll do are designed to work your hand and
elbow in ways that are similar to your work tasks and
sport activities. Your therapist will help you find
ways to do your tasks that don't put too much stress
on your elbow.
You may need therapy for two to three months. It
may take four to six months to get back to high-level
sports and work activities. Before your therapy
sessions end, your therapist will teach you a number
of ways to avoid future problems. |