Golfer Elbow

Medial epicondylalgia: degenerative tendinopathy at the common flexor and pronator origin on the medial epicondyle of the humerus, mainly involving the pronator teres and flexor carpi radialis. It is a tendinosis with disorganised collagen, not a true inflammation.

• It is about 5 to 10 times less common than lateral epicondylalgia, affecting about 0.3 to 0.6% of adults, with peak age 35 to 55 years. Most patients are not golfers. Typical causes are repetitive forceful wrist flexion, forearm pronation and gripping (golf, throwing sports, racquet sports, weightlifting, climbing, carpentry, hammering, plumbing and assembly line work).
• Risk factors: repetitive flexion and pronation, poor technique, age, obesity, smoking, diabetes, and previous elbow injury.
• Natural history: most cases resolve over 6 to 12 months, and about 85 to 90% recover without surgery.
• Coexisting ulnar neuropathy at the elbow occurs in about 20 to 60% of patients, because the ulnar nerve lies behind the medial epicondyle.

• Medial elbow pain, radiating to the forearm, worse with gripping, lifting, throwing, and resisted wrist flexion and forearm pronation. Morning stiffness may be present. Weakness of grip.
• Examination: tenderness 5 to 10 mm distal and anterior to the medial epicondyle, pain on resisted wrist flexion and pronation, pain on passive wrist extension with the elbow extended, and a normal elbow range of movement.
• Ulnar nerve involvement: tingling in the ring and little fingers, positive Tinel sign behind the medial epicondyle, pain on elbow flexion with provocation, and weakness of grip and pinch.
• Differential diagnosis: ulnar collateral ligament injury (valgus instability, in throwers), cubital tunnel syndrome, medial epicondyle apophysitis or avulsion (adolescents, "Little Leaguer elbow"), flexor pronator muscle tear, cervical radiculopathy (C8 or T1), brachial plexus lesion, elbow osteoarthritis, osteochondritis dissecans, medial antebrachial cutaneous neuritis, and nerve entrapment in the forearm (pronator syndrome).
• Red flags: trauma, locking, instability, night pain, fever, or neurological weakness.
• Complications: chronic pain, loss of grip strength, ulnar neuropathy, and tear of the flexor origin.

• Clinical, with examination of the elbow, ulnar nerve, cervical spine and the stability of the ulnar collateral ligament (valgus stress test, milking manoeuvre).
• X-ray for persistent pain, trauma or suspected calcification, loose bodies, or osteophytes. In adolescents, X-ray for apophyseal avulsion.
• Ultrasound shows tendon thickening, tears and calcification. MRI for ligament injury, tendon tear, or uncertain diagnosis.
• Nerve conduction studies and electromyography if ulnar neuropathy or cervical radiculopathy is suspected.

• Education and activity modification: reduce repetitive gripping, wrist flexion and pronation, correct technique (golf swing, throwing mechanics, grip size, equipment), and use ergonomic tools. Gradual loading rather than complete rest.
• Analgesia: paracetamol 1 g orally 6 hourly. Topical diclofenac 1% gel 2 to 4 g 3 to 4 times daily. Oral NSAIDs (ibuprofen 400 mg 8 hourly with food, for 1 to 2 weeks at most) give short term benefit only.
• Ice for 10 to 15 minutes after activity for symptom control.
• Exercise therapy (the main treatment), 3 to 4 times weekly for 8 to 12 weeks:
  • Isometric wrist flexion and pronation holds early (45 seconds, 4 to 5 repetitions).
  • Progressive eccentric and heavy slow resistance strengthening of the wrist flexors and pronators, with gradual return of grip, forearm and shoulder strength, and flexor stretching.
• Support: a counterforce strap below the elbow during activity, and a wrist splint at night for painful cases.
• Corticosteroid injection provides short term relief but has poorer long term results than exercise, and risks injury to the ulnar nerve (which lies close). If used: triamcinolone acetonide 10 to 20 mg with lidocaine 1% 1 to 2 mL around the tender site, with the elbow extended to move the ulnar nerve away, and not more than 1 to 2 injections. Avoid in patients with ulnar nerve symptoms.
• Other options with limited evidence: platelet rich plasma (a single injection of 2 to 3 mL), extracorporeal shock wave therapy (3 weekly sessions), and glyceryl trinitrate patch 1.25 mg per 24 hours (a quarter of a 5 mg per 24 hour patch) daily for 6 to 24 weeks.
• Surgery for refractory pain after 6 to 12 months of treatment: debridement of the degenerative flexor pronator origin with repair, and ulnar nerve decompression or transposition when neuropathy coexists, with success in about 80 to 90%. Rehabilitation takes 3 to 6 months.
• Ulnar neuropathy: night extension splint, avoidance of prolonged elbow flexion and leaning on the elbow, and decompression if there is persistent sensory loss, weakness or muscle wasting after 3 months.
• Special groups:
  • Adolescent throwers: stop throwing for 4 to 6 weeks or more, correct mechanics, and treat the medial apophysis (Little Leaguer elbow). Surgical fixation only for displaced avulsions.
  • Pregnancy: ergonomic changes, brace, physiotherapy and paracetamol. Avoid NSAIDs after 20 weeks.
  • Diabetes: monitor glucose for 3 to 5 days after injection, and expect slower recovery.
  • Smokers: advise cessation.
  • Renal impairment and gastrointestinal disease: avoid oral NSAIDs.
• Follow up: review at 6 weeks and 3 months. Refer to orthopaedics, sports medicine or hand surgery for no improvement by 6 months, ligament instability, ulnar nerve symptoms with weakness, or diagnostic doubt.