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Sports injury specialist

GOLFER's ELBOW

What is Golfer's elbow?

Golfers Elbow is also known as medial epicondylitis. It is similar to tennis elbow except that it affects the inner aspect of the elbow (the medial epicondyle) rather than the outside of the elbow.

Why does it occur?

No one knows, but it is thought to be due to degeneration of the flexor muscles of the hand and wrist that attach to the inner side of the elbow. Though it is called Golfers elbow it is not seen only in golfers.

It is thought that the elbow is injured by repetitive eccentric loading of the muscles which flex the wrist and pronate (twist) the forearm, combined with a valgus (outward) stress on the elbow. These muscles are attached to the inner side of the elbow by a common tendon (common flexor tendon- see fig.1)

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and are stimulated to contract by valgus overload of the elbow (eg with overhead throwing). If this happens repeatedly, there can be micro tears in the tendon and degeneration. Eventually the normal tendon can be replaced by abnormal degenerate tissue. In severe cases the underlying stabilizing ligaments of the elbow can get damaged with resultant instability of the elbow.

What are the symptoms?

There is a gradual onset of pain over the inner side of the elbow (see fig.2).

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The pain can radiate from the elbow into the front of the forearm into the wrist. Pain may be increased when patients with this condition try and grip something or twist the forearm like turning a door handle. There may also be discomfort in extending (straightening) the wrist due to stretching of the affected flexor muscles.

In the athlete, this condition is typically associated with overhead throwing, golf or tennis. The pain is often felt at the beginning of the acceleration of the golf swing or tennis serve.

In the workplace, it is associated with occupations involving repetitive forceful grip, manual handling of heavy loads or exposure to constant vibration.

How is it diagnosed?

The diagnosis is usually made from the history and the clinical examination. Occasionally x-rays or a scan may be ordered to exclude other conditions.

How is it treated?

Golfer’s elbow is always treated non-operatively to start with. Your doctor may advise rest and modification of activities, anti-inflammatory tablets, and a special elbow support. Physiotherapy is also useful in many patients. Physiotherapy may include acupuncture, pulsed ultrasound, deep friction massage and a home exercise program.

A forearm strap (counterforce brace) can be worn just below the elbow to limit the stress on the muscles.

If none of the above measures work then a steroid injection given in the region of maximum tenderness can resolve the symptoms. It may be a few days before the symptoms improve. The steroid does not produce any harmful effects in the rest of the body.

Recently the use of PRP (Platelet Rich Plasma) injections has become more popular. This involves taking a blood sample and spinning it at high speeds in a centrifuge for a few minutes. This separates the blood into a number of layers. The layer containing growth factors and special cells called platelets that promote healing is then injected into the painful area. Some studies have shown good results in the treatment of tennis & golfer’s elbow.

Will an operation be required?

If symptoms persist despite trying all the above measures then an operation is advised. The operation is usually performed using a small incision under a general anesthetic. On average 85% of patients will get complete relief of their symptoms, 10% get some relief but 5% see no benefit.

How long does it take to recover from the operation?

The operation is done as a day case, so you will be able to go home the same day. You will be given painkillers to use once the local anaesthetic wears off. You will wear a sling for the first few days in order to keep your hand elevated, thus avoiding swelling and stiffness. The physiotherapist will show you finger and wrist exercises to do. You will have a bulky wool and crepe dressing on the elbow which you can remove 2 to 3 days after the operation. The smaller underlying adhesive dressings should be left alone. You will need to keep your dressing/wound dry. You will be seen for a follow up about 10 to 14 days after the operation for wound inspection and suture removal (however sometimes absorbable sutures are used). At this stage you can start bathing as long as your wound is completely healed with no wet/oozy areas. The physiotherapist will then see you. Physiotherapy is a vital part of the post-operative recovery.

Complications

Complications from this procedure are rare. Watch for any signs of infection; if you experience any of the following

  • Increasing pain in the wound after the obvious initial discomfort.
  • Increasing redness and/or swelling.
  • Unpleasant discharge.
  • Swelling is normal and will generally settle down on its own with elevation and appropriate physiotherapy.

Swelling is normal and will generally settle down on its own with elevation and appropriate physiotherapy.

Returning to Work/ Driving

Your comfort level should be your guide for returning to work. Most people are able to return to work within one to two weeks, but it does depend on the kind of work you do. If you have a heavy manual job then you may need to be off work for three weeks or more. Patients are normally advised not to drive for one week; driving is only allowed once you feel that you can control the car and you can turn the steering wheel in an emergency.

Sports Activities

You will need to avoid playing sports for a certain time after the operation. This time can be anything up to 12 weeks after your operation, depending upon your sport. It may take up to 3 to 6 months for the elbow to return back to normal following the operation.

Are there any other methods of treating golfer's elbow?

Ultrasonic shockwave therapy has been tried. However this method is still experimental and its benefit is yet to be proved

Can golfer's elbow be prevented?

To prevent golfers elbow from reoccurring, it is important to make sure you perform various exercises to strengthen the flexor muscles. Initial rehabilitation aims to regain a full painless range of movement. This involves open-chain (non weight bearing) exercises and self-stretching exercises (see fig.3)

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Once a good range of movement has been achieved, then strengthening begins. This involves concentric open and closed chain exercises (A concentric exercise is one in which the muscle shortens). Finally eccentric exercises are implemented (exercises in which the muscle lengthens).

You must use the proper form while playing sports and when doing any heavy lifting in the gym etc. Warming up before starting to use the muscle will also help prevent the condition. After exercising, you may want to ice and stretch the elbow and arm muscles. This will be explained in detail by the physiotherapist.

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