Golfer’s elbow, also termed Medial epicondylitis, is tendinopathy (inflammation of the tendon) of the inner side of the elbow. There are a group of muscles that have a common attachment called as flexor tendon. A golfer’s elbow is a result of overload or overuse injury of this flexor tendon. Referring to different professions it goes by many names, pitcher’s elbow, suitcase elbow, baseball’s elbow. In medical terminology, it is also called tendinosis or epicondylalgia, or epicondylitis.

There are two main points in an elbow joint, lateral epicondyle and medial epicondyle. These two points are located in the arm bone called as Humerus.

All the forearm muscles are attached to these two points. The medial epicondyle is the focal point in a golfer’s elbow, as it is a common origin of the flexor muscles (which bend the wrist towards the palm) and pronator muscles (which rotate the forearm inwards)  of the forearm. The muscles called pronator teres, flexor carpi radialis, palmaris longus, and flexor digitorum superficialis take their origin from the medial epicondyle and nerve supply is by the median nerve.

The muscle flexor carpi ulnaris is also attached to the medial epicondyle and the nerve supply is by the ulnar nerve.

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In conjunction, these five muscles share the same origin and form the flexor tendon of the medial epicondyle of the humerus (arm bone).

This flexor tendon is three centimeters long, runs parallel to a structure called the ulnar collateral ligament, and serves the purpose of a  stabilizer of movement.

Source: prehabservices.com

WHAT CAUSES GOLFER’S ELBOW?

If you suffer from inner elbow pain and you play a game like a baseball or a golf, where repeated activities of the wrist and forearm are needed; you may have Golfer’s elbow.

The prime cause is repetitive stress by forceful finger and wrist movements. This injury eventually leads to tendinopathy (a condition where the tendon gets inflamed).

Repetitive activities cause microtears and the failure to heal properly causes the degeneration of the Flexor-pronator tendon.

If you have a golfer’s elbow, you will present with a painful and swollen affected elbow joint. The pain resolves when you stop any activity involving elbow movement. You may have symptoms like elbow stiffness, weakness, tingling, or numbness. All these symptoms along the inner side of the elbow extend up to the little finger, the distribution of the ulnar nerve. The most sensitive region is located near the origin of the wrist flexors on the medial epicondyle of the humerus.

You may want to understand what goes inside the elbow if you are diagnosed with a golfer’s elbow. As medial epicondylitis or Golfer’s Elbow is a cumulative disorder, tendinopathy (inflammation of the tendons) occurs due to overuse of the muscles of the elbow.

The chronic repetitive muscle shortening and lengthening  (concentric or eccentric muscle contraction) results in wear and tear inside the muscles which bend the wrist. A group of muscles flexors present on the inner side of the elbow and a muscle called pronator teres undergo angiofibroblastic changes.

The term angiofibroblastic changes mean the muscle-tendon fibers are invaded by a particular cell called fibroblast which connects the micro-tears but makes the tendon weaker and less elastic. Repeated wrist bending hampers healing and degeneration of the surrounding tissues takes place. Thus, this repetitive activity leads to micro-tears within the tendon and subsequent inflammation with classic signs such as swelling, redness, and heat in the affected area.

Earlier it was thought that the pronator teres and flexor carpi radialis were most commonly affected, the literature by Descatha A, Leclerc A, et al determined that all muscles are affected equally except for the muscle called palmaris longus. As the tendon has micro-tears, this results in the remodeling of the collagen fibers; and increased mucoid (a gelatinous substance also called Wharton’s jelly) ground substance. Local necrosis( death of tissue) or calcification (deposition of calcium in the healing tissue which may harden the tissue) can also take place. Such inflammatory processes make the collagen tissue which is already present in muscles and tendons become weak. As the tendon strength decreases this may lead to increased brittleness, formation of scar tissue, and thickening of the body of the tendon. Although rare, if you suffer from acute trauma medial epicondylitis may take place from a sudden violent contraction of the muscles. 

WHO CAN SUFFER FROM A GOLFER’S ELBOW?

Athletes who are likely to develop golfers elbow when they use forceful wrist and forearm movements are American football players, people who play tennis and other racquet sports, archers, some weightlifters, and javelin throwers.

Shiri R et al did a population study and found that pitchers ( baseball players) and overhead throwing athletes often develop medial elbow pain because of high energy valgus forces during the late cocking and acceleration phase. Confused??? Let me explain in an easy way!

Overhead activities are especially taxing on athletes as they face high stress on their bones when throwing overhead with great force. The valgus force mentioned above makes two bones in a joint to be approximated really fast. This action pulls on the tendon and repeated throwing puts it under tension.

Source: www.ndtv.com

In the golfers from where the name originated, Shiri R et al determined that it may occur from the top of the backswing ( an imaginary line on which the golf club tracks during the movement) to the moment before ball hits the golf club.

Source: www.golfdigest.com 

Shiri R et al also found that almost 90% of reported cases were not related to sports.  Occupations that include intensive labor, and forceful and repetitive activities are implicated. Some examples of the professions like construction, carpentry, and plumbing.

HOW DO WE TREAT MEDIAL EPICONDYLITIS OR GOLFER’S ELBOW?

• If you suffer from medial elbow pain and have been diagnosed with a golfer’s elbow please visit a Physiotherapist as soon as possible.
• As it is only the Physiotherapist who can assist in healing and correcting the disorder, you can start to heal within a short period of time by learning all the exercises and electrotherapy treatments.
• According to a study, the researchers Hoogvliet P, Randsdorp R, et al found that Physiotherapy is the primary management choice for medial epicondylitis. The long-term goal of the treatment process is to provide a full, painless range of motion at the wrist and elbow. The Physiotherapy sessions will include muscle strengthening exercises after your pain has been managed. Multiple modalities may be used depending upon your condition. Name a few modalities which provide immense relief include ultrasonography for enhanced healing, iontophoresis for good blood circulation, phonophoresis for better penetration of painkilling ointments, dry needling to relieve trigger points, extracorporeal shock wave therapy, electrical stimulation to maintain muscle mass and prevent wasting.
• Cryotherapy is immensely useful in taking down the initial inflammation. Soft tissue and manipulation techniques like friction massage of the tendon may break the scar tissue and make the affected area flexible to allow more vigorous strengthening and stretching. Eventually resulting in a faster and full recovery from the symptoms of the golfer’s elbow. Night splinting with a special splint prescribed by the physiotherapist may be helpful. A special brace can prevent the muscle to contract with full force and unload the tendon hence making the activities less painful. Elbow taping done by an expert with kinesiology taping is useful in some cases.

Low-Level Laser Therapy AKA Cold laser Treatment For Golfer’s Elbow

A booming option for the treatment of the golfer’s elbow. A therapy your Physiotherapist will suggest if you have a golfer’s elbow is Laser therapy. Cold laser therapy really helps with the healing of the injured tissue. How laser therapy heals is by increasing collagen production.

The cold laser therapy decreases new scar tissue formation and promotes the breakdown of the existing scar tissue. The laser light encourages collagen production, making the healing better. Cold laser therapy is beneficial in increasing the endorphins and enkephalins, which block the pain signal to the brain and will reduce the pain sensation. Thus, low-level laser therapy decreases nerve signals of pain and takes down the perceived pain. Good blood flow due to increased formation of capillaries by laser therapy will carry nutrients such as proteins to the injured tissue. Increased blood flow also takes away the waste products, thereby enhancing the healing at a cellular level. Laser plays a major role in healing nerves. Nerves heal very slowly. Laser therapy accelerates this process.  

Low-level laser therapy increases cellular ATP. ATP is the ultimate source of energy for cells, it is the energy source that cells operate. Injured cells often have low levels of ATP, which decreases their ability to heal and repair. Low-level laser therapy may relieve trigger points and acupuncture points are stimulated to decrease muscle and joint pain. A Physiotherapist will a different treatment approach for an athlete with a golfer’s elbow. A Sports Physiotherapist will make you go through several drills to enhance your performance after proper evaluation of the throwing arm/ dominant arm with which you play.

A study done by Steve Tumulty was a meta-analysis of several studies that found evidence as to the effectiveness of cold laser therapy in the treatment of tendinopathy. However, an optimum dosage window was determined which was beneficial in the treatment of the golfer’s elbow. Strong evidence was extracted from the 12 good studies that positive outcomes were related to laser therapy with the use of dosage mentioned.

Return to work rehabilitation for golfer’s elbow is different in people with different occupations like plumbing and mechanical work. Carpenters will need an ergonomic consultation for proper handling of the instruments so that it is not taxing to the already injured muscles.

Every person has a different perception of pain and a different level of muscle strength so, every Physiotherapy treatment is customized for a new case. If you feel persistent pain after therapy, you need an Orthopaedic consultation as soon as possible.

Reference:

• Hoogvliet P, Randsdorp MS, Dingemanse R, Koes BW, Huisstede BM. Does the effectiveness of exercise therapy and mobilization techniques offer guidance for the treatment of lateral and medial epicondylitis? A systematic review. Br J Sports Med. 2013 Nov;47(17):1112-9.
• Descatha A, Leclerc A, Chastang JF, Roquelaure Y., Study Group on Repetitive Work. Medial epicondylitis in occupational settings: prevalence, incidence, and associated risk factors. J Occup Environ Med. 2003 Sep;45(9):993-1001. 
• Shiri R, Viikari-Juntura E, Varonen H, Heliövaara M. Prevalence and determinants of lateral and medial epicondylitis: a population study. Am J Epidemiol. 2006 Dec 01;164(11):1065-74?
• https://www-hopkinsmedicine-org.cdn.ampproject.org/v/s/www.hopkinsmedicine.org/health/conditions-and-diseases/medial-epicondylitis-golfers-and-baseball-elbow.
• Okuni I, Ushigome N, Harada T, Oshiro T, Musya Y, Sekiguchi M. Low-level laser therapy for chronic joint pain of the elbow, wrist, and fingers. Laser Ther. 2012;21(1) :15-37