Golfers elbow

What is Golfer’s elbow?

Elbow joint is formed by three bones, humerus (arm bone), radius and ulna (forearm bones) supported by muscles and tendons. It is the second most mobile joint of the body. Golfer’s elbow or medial epicondylitis is an inflammatory condition of the tendons that attach muscles to the medial epicondyle (a bony bump on the inside of the elbow joint) at the elbow.  These muscles are essential to bend (flex) your wrist and fingers (clench). The tendons of these muscles are irritated and inflamed due to the overuse or strain or injury or repetitive actions. This usually happens in sports like golf, weight training, baseball, football, javelin, racquet sports like tennis and in certain jobs like painting, cooking, plumbing, butchering, weight lifting etc where there is repeated bending of the wrist and clenching of fingers. Sometimes, it is associated with inflammation of the ulnar nerve, carpal tunnel syndrome, lateral epicondylitis (tennis elbow) or rotator cuff tendinitis.

Golfer’s elbow and tennis elbow are similar problems of the elbow but the incidences of golfer’s elbow are 5 -10 times lesser. Males and females are equally affected in the age group 30-60 years, commonly in the third and fourth decade. It affects the dominant arm in 75% of cases.

 

What are the symptoms of Golfer’s elbow?

Its symptoms include pain and tenderness felt on the inner side of the elbow. The pain may radiate to the inner side of the forearm and sometimes to the hand. Pain is felt most when the wrist is bent towards the forearm or during gripping. Stiffness in the elbow is also common. You may feel weakness in the hands or wrists. The stiffness and pain is usually worse in the morning (after a period of rest) and gets slightly better on repeated use of the arm. A numb or tingling sensation may be felt that may radiate to the fingers usually ring and little fingers, if the ulnar nerve is involved.

 

How is it diagnosed?

Your orthopaedic surgeon will diagnose medial epicondylitis after discussion of your symptoms, and physical examination. He will ask for ultrasound scan/MRI scan/x-rays to study the extent of the damage to this area and plan the treatment. He may also ask you to have EMG or electromyography to check the involvement of the nerves.

 

What happens if nothing is done?

If golfer’s elbow is left untreated, it may recover by itself if the causative factor (sports, work etc) is stopped. If the activity is continued, it may lead to chronic pain, tendon tear, weakness and limited range of motion in the elbow.

 

How is it treated?

It can be treated conservatively or surgically. Conservative treatment involves rest, activity modification, ice application, medications, steroid injections, splint/counterforce brace, physical therapy, and PRP injections.

Surgery is indicated in

  • Failure or non-responsiveness to conservative treatment (6-12months)
  • Persistent pain
  • Associated pathology – ulnar nerve compression, fracture etc

 

What are the non-operative treatments?

The non-operative treatments involve the following-

  1. Rest– resting your arm can be achieved by avoiding the activities that can provoke pain. This enables proper healing of the tendon without new injury or trauma.
  2. Ice application– you can apply ice packs for 15 to 20 minutes at an interval of three to four times in a day. It controls the pain and swelling of the affected area.
  3. Medicines– your surgeon will give you painkillers like paracetamol or codeine to reduce your pain. Anti-inflammatory medicines like aspirin and ibuprofen are also prescribed to reduce your pain and swelling however long-term use can affect your stomach and kidneys.
  4. Brace– your surgeon can advise you to use counterforce brace or splint for your affected arm in order to reduce strain on your muscles and tendons.
  5. Physical therapy- physical therapy is necessary to regain the lost strength and range of motion and prevent stiffness in the joint. It is started with gentle stretching exercises of the elbow after immobilization in a sling. It is followed by strenuous and strengthening exercises of the elbow. It should be done under the supervision of your surgeon and physiotherapist.
  6. Acupuncture – This could help with the pain in early stages in some patients.
  7. Steroid injections- your surgeon can inject corticosteroid directly into your tendons to reduce inflammation. However, this treatment provides instant relief but it may not last longer.
  8. Plasma-rich protein injections- plasma rich protein injections are given to repair the damaged tissues of the affected site. These injections are basically derived from your own blood plasma, however the results are not promising more than steroid injection.

 

What does the operation involve?

The main goal of the operation is to relieve the symptoms, remove the damaged tissues and improve the blood supply to the affected site for proper healing.

It is usually done by open surgery.

  • The operation is done as a day case under general anaesthetic, the skin over the affected area is cut and damaged tendon tissues are removed. Scar tissues and bony projections if present is removed. The bone is drilled to improve blood supply and the remaining tendon is repaired back to the bone.
  • The skin is then stitched with absorbable sutures, a bulky bandage is applied to the elbow. The operation takes 1- 2 hours and most patients are discharged on the same day after 4 hours of operation.

 

What happens after surgery?

  • The local anaesthetic wears off 4-10 hrs after surgery, patients are encouraged to start taking painkillers before the pain starts i.e. on return home and for at least 48 hours from there. This way most of our patients report little or any pain.
  • Before discharge, your physiotherapist will teach you gentle exercises of fingers, wrist, elbow and shoulder. This is necessary to prevent further stiffness and to maintain the strength of the muscles.
  • The bulky bandage could be removed in 48hrs and dressings over the wound kept clean and dry for 2 weeks
  • Heavy activities and weightlifting should be restricted for 4-6weeks to ensure safe healing. You can use your arm to do light activities (writing, using keyboard etc) that don’t cause excessive pain or discomfort.
  • The patient is reviewed at 2 weeks and referred for physiotherapy.
  • The wound should be massaged (typically after 2 weeks) using the moisturizing cream by the patient 3 times a day for 3 months once the wound is well healed. This reduces the scar sensitivity and scar-related complications and helps the scar to mature.
  • The physical therapy after Golfer’s elbow release is paramount and is essential to start them as soon as possible after surgery. Gentle exercises as tolerated by the patient after surgery and are progressed to stretching exercises around 2-4 weeks. This will be guided by your surgeon and physiotherapists. The improvement in movements happens over a period of 3- 6 months and is dependent on the complexity of the primary problem and the intervention.

 

Are there any risks?

  • Persistent elbow stiffness
  • Infection
  • Nerve injury (ulnar)
  • Vascular injury (uncommon, brachial artery)
  • Myositis ossificans
  • Recurrence
  • Anaesthetic complications
  • Chronic Regional Pain Syndrome “CRPS”.
  • Any surgery can end up with rare complications and leave a patient worse than before surgery and is rare in this surgery

 

What are the results of the operation?

The outcome of the surgery is good with minimal serious complications (<1%). The outcome following this surgery depends on severity/chronicity of the injury, treatment involved and adherence to physiotherapy. However, is more predictable in the author’s experience.

 

When can I return to driving and work?

You can get back to work in 2-4 weeks if you have a desk job, however might take upto 3 months if your job involves physical work. Regarding return to contact sports, it usually takes 3 months and you should be able to resume driving in 4-6 weeks. The above time line could vary based on the severity of injury and the treatment modality.  Your physician will be able to advise you.

Golfers_elbow

Pain originates from the inside of elbow and radiates to palmar side of forearm.

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