Golfer's Elbow

Pain on the inside of the elbow is commonly called Golfer’s Elbow or Medial Epicondylitis. It is a condition that develops from repetitive use of the hand and elbow. Activities that can trigger this condition include repeatedly swinging a golf club or other activities that require repetitive gripping, twisting or throwing. Working at a computer, performing yard work, athletes with repetitive overhead motions, carpenters, and plumbers are most at risk.?

History:

“Medial Epicondylitis” was traditionally the medical term for Golfer’s Elbow, with “itis” indicating an inflammatory component. Treatments were focused on reducing inflammation, such as ice, anti-inflammatories, and steroid injections. But ten years ago, the research found this to be a misconception.?The?inflammatory stage?only lasts a few days.?Pain that continues for more than six days could no longer be attributed to inflammation.

The cause of epicondylitis was then theorized to result from the?tendon?not healing correctly (where the muscle attaches to the bone). With continued use, micro-retearing would occur due to a weakened tendon. Tendonitis was changed to “Tendinosis” – instead of inflammation, the focus was poor tendon healing. Treatments for tendinosis consisted of stretching and eccentric strengthening to improve the recovery of the tendon. Some did find relief, but many also went on to become chronic.

Recent research has found that?a high percentage of those with elbow pain have a “joint derangement” or?mechanical disorder?that interferes with the normal function of the medial elbow joint. It sounds daunting but is usually easily treated!

The Cause:

Golfer’s elbow is a condition that occurs due to repetitive use of the forearm, either disrupting the cartilage within the elbow joint or causing irritation to the medial tendons of the forearm. Pain from Golfer’s elbow is located at a?bony bump on the inside of your elbow, known as the medial epicondyle. This is where the tendons to your wrist/finger flexors and pronator muscles attach. It is also where the pain is referred from a problem within the joint or a ligamentous tear.?

Causes of Pain:

1.?Inflammatory

Acute damage to the medial elbow will initiate a chemical process producing inflammation.?A constant throbbing pain characterizes the inflammatory phase.?Inflammation is critical to the healing process. It allows chemicals to be released to clean up the area, increase blood flow, and heal any damaged tissues and bone.?The inflammatory stage is short-lived, only lasting a few days.

2.?A problem within the medial elbow joint:

Joints have cartilage protecting the outer layer of bone and an extra buffer between the bones.?(Examples of cushions between bones: Meniscus in the knee; labrum in the hip/shoulder, the disc in the spine.)?

Repetitive motion strains the joint, especially if the movement is awkward or has poor mechanics. This strain can cause microscopic tears in the cartilage and even give rise to a tiny piece of your cartilage breaking off. This is part of the natural wear and tear process, but excessive activity combined with poor mechanics will advance this breakdown, known as a “derangement .”Even though this piece is very small, it can cause pain and loss of motion if it interferes with the joint’s smooth mobility.?Derangements are characterized by intermittent pain, pain during movement, and a loss of motion?(can be constant pain if joint is held in an abnormal position such as a dislocation).

3. A problem within the medial muscle tendons

Tendons are soft tissue at the end of the muscle that attache the muscle to a bone. Repetitive forces can cause a microscopic breakdown in the cartilage and/or cause the tendon to become tender and irritated. When the tendons break down, the newly repaired tissue needs to be stretched and strengthened to imitate its original state. When a repaired tendon does not regain proper strength and flexibility, it is prone to re-injury. The group of muscles affected by Golfer’s elbow are those that bend the wrist, fingers, and thumb and pronate (turn or hold) the wrist so that the palm faces downward. Pain secondary to a tendon dysfunction is characterized by tissue tightness and muscular weakness.

Symptoms

• Pain along the inside of the forearm with wrist, hand, or elbow movements, especially gripping or squeezing.
• Tenderness to touch and swelling along the inside of the forearm.
• Weakness in the hand and forearm when gripping objects.
• Elbow stiffness and loss of ability to fully straighten the elbow the last 5-10 degrees.

Importance of a Proper Diagnosis?

Golfer’s Elbow is a generalized term for any localized injury to your medial elbow. A thorough evaluation must be performed to decipher the true cause of your elbow pain.?First other conditions need to be ruled out, including referred pain from your neck, inflammatory arthritis, gout, fracture, ligament tear/instability, dislocation, and infection.

Once it is determined that you do have Golfer’s elbow or an overuse injury localized to the inside of your elbow, your clinician will then assess further to determine one of the following:

1. Inflammatory condition

2. Joint problem (internal derangement)

3. Tendon injury that failed to heal correctly (dysfunction)

Your physical therapist will perform a thorough evaluation. They will ask you questions about any pain or other symptoms you may have and what activities/positions aggravate and relieve your symptoms as well as your hobbies and job duties.?A physical exam will be performed and include the following:

• Observe for any abnormalities (edema, redness, irregularities in bones, ligaments, muscles, etc)
• Rule out your spine as the source of pain
• Test your strength?
• Assess your range of motion in your wrist, forearm, and elbow.
• Assess for ligamentous laxity
• Perform repeated movements and assess their effect on your baselines

Treatment for Golfer’s Elbow:

Proper treatment must begin with an accurate diagnosis.?Unfortunately, elbow pain is often misdiagnosed as tendonitis or an inflammatory condition. Chemical or inflammatory pain is constant and short-lived. Examples of pain from inflammation are a toothache or hitting your thumb with a hammer – a continuous, throbbing pain. When tissue damage is from an injury or infection, the body releases chemicals to initiate the healing process to clean the area and increase blood flow to repair tissues.

Elbow pain brought on with activity such as turning a doorknob, brushing your hair, gripping, but not painful at rest cannot be from inflammation.?Intermittent pain is from a mechanical source or disruption within the joint.

Most often, medial elbow pain is intermittent and brought on only with activity.?A mechanical exam is required to determine the root cause of your pain.?An MRI will show abnormalities but does not differentiate painful from non-painful tissues. We can only ascertain what is working and what is painful by using and moving the joint and soft tissues.

Most pain from Tennis Elbow is the result of a problem within the joint, known as a derangement. Pain from a derangement is usually easily corrected. This mechanical problem needs to be cleared. (If you have a pebble in your shoe, walking is painful. If you shake your foot, so the pebble moves into your toe box, you can now walk without pain.?The stone is still there. You just moved it out of the way.)?Similarly, if you can move the small particle out of the joint’s arc of motion, you will no longer have pain. The body will break down the particle when it is out of the joint space.

The derangement can be anywhere within the joint. Often there is a loss of the ability to straighten the elbow fully and pain when attempted. This particle must be cleared or removed out of the joint space. A way to test is to find a baseline or activity that causes pain. It could be squeezing something or resisting as you extend your fingers. Perform that painful activity and assess your pain. Next, straighten your elbow and then relax by bending it slightly. Perform this ten times, each time trying to go a bit further into extension or straightening your elbow. Retest your baseline activity. Do you have more, less, or the same amount of pain performing?

If you have less…Great…you found your self-treatment!

If there is no change, then it could still be a derangement. It would help if you had further guidance to find the right direction to clear the derangement. Or you may have poor tissue healing – Tendinosis. A clinician specializing in Mechanical Assessment and Treatment will advise you on what you need to abolish the pain.?

How Can Virtual Physical Therapists Help?

There is no reason for you to suffer in pain when you can get relief now! It is also essential to get treatment for Golfer’s elbow as soon as it occurs because the tendons are affected and do not have a good blood supply. An inflamed tendon that goes untreated can begin to tear, and a more severe condition can result. If you have a derangement, it can easily be treated, and you can get relief right away!

Can This Injury or Condition Be Prevented?

Understanding the risk of injury and being aware of your daily movements can help prevent elbow pain.?

• Use proper form and technique when repetitive tasks or sports movements, like golf swings.
• Maintain shoulder, forearm, and wrist muscle strength.
• Perform gentle forearm muscle stretches before and after performing tasks.
• When lifting heavy objects, use proper posture and body mechanics to reduce joint strain.
• Listen to your body when you have pain. Active rest periods are critical for full healing after exercise.