pathology: Golfer’s elbow

Golfer’s elbow

Definition

Some authors equate thrower’s elbow with golfer’s elbow. This is not correct: thrower’s elbow primarily describes ligamentous instability of the medial elbow joint, whereas golfer’s elbow is a tendinopathy or enthesopathy of the forearm flexors and pronator teres originating at the medial epicondyle. Golfer’s elbow is an insertion tendinopathy (enthesopathy) of the forearm flexors or pronator teres originating at the medial epicondyle of the humerus: an aseptic inflammatory or degenerative process at the origins of pronator teres, palmaris longus and flexor carpi ulnaris; depending on the source, flexor carpi radialis and flexor digitorum superficialis are also included. Typically, pronator teres or flexor carpi radialis is affected. Other forearm flexors may be involved depending on the loading pattern.

Depending on the movement and therefore the muscles affected, three types of golfer’s elbow can be defined:

Mixed types can of course also occur.

The distinction between golfer’s elbow and thrower’s elbow also entails differences in prognosis and treatment. While conservative treatment of thrower’s elbow can hardly provide lasting relief (muscle strengthening can compensate for ligamentous insufficiency only inadequately), golfer’s elbow, especially in acute cases lasting less than six months, is treated almost exclusively conservatively. Golfer’s elbow is a relatively common overuse syndrome. An initial reactive inflammatory component may be present. In chronic cases, however, degenerative-reparative tendon remodeling usually predominates, with altered collagen structure, neovascularization, myofibroblasts and tendon swelling. The term epicondylopathy is therefore often preferable in chronic cases.

In addition to overuse, valgus loading of the elbow joint may play a role. The condition closely resembles tennis elbow. When tissue damaged by microtrauma is not given sufficient time to repair, degenerative changes occur. The collagen fibrils reorganize and lose their parallel alignment. Angiomyofibroblastic proliferation, neovascularization and infiltration by myofibroblasts also occur. Tissue calcifications are occasionally observed. The flexors attach tendinously together with pronator teres at the anterosuperior medial epicondyle of the humerus; this tendon is known as the medial conjoint tendon (MCT). The insertion of the anterior portion of the medial collateral ligament, also called the anterior oblique ligament (AOL), lies close to the MCT. Medial epicondylitis is considerably less common (approximately 7 to 10 times less common) than lateral epicondylitis and accounts for about 10–20% of epicondylopathies. In population studies, its prevalence is usually below 1%. There is likewise a concentration in later decades of life, from the third to the fifth decade. Reports of sex distribution vary. Some reviews report medial epicondylitis to be about twice as common in men, while others find little difference in risk between men and women. The dominant arm is usually affected; reviews report this in approximately 75% of cases. Trauma can trigger golfer’s elbow. Much more commonly, however, it results from repetitive, forceful loading (overuse) of the flexor–pronator group. Activities that create valgus stress at the elbow increase the likelihood and severity of the condition. Occupational activities involving repeated forceful gripping, wrist flexion and forearm rotation may increase risk; they are sometimes reported to account for 50% of cases. Sports involving powerful throwing, striking or gripping movements may also contribute. Associated sports include baseball, football, javelin throwing, bowling, tennis, swimming and golf; in golf, in particular, inertia creates valgus stress both during acceleration of the striking arm and when the club strikes the ball. Cubital tunnel syndrome may occur as an accompanying condition or differential diagnosis of golfer’s elbow. Treatment-refractory or neurologically significant symptoms warrant targeted neurological and, if necessary, neurophysiological assessment. Depending on the source, 20–24% of treatment-refractory cases are reported to require surgical release. The Gabel classification therefore distinguishes:

Tenderness occurs at the medial epicondyle and in the tendon tissue up to 10 mm distal to it. Pain on loading occurs during wrist palmar flexion or stabilization against dorsiflexion moments, together with stretch pain. Pronation may also be painful, depending on the precise presentation. Affected individuals may noticeably avoid elbow extension. Pain on resisted pronation is a particularly frequent and sensitive finding. Pain on resisted wrist flexion is also typical. One source reports 90% and 30%, respectively, for these two findings. Pronation is then painfully restricted, which is readily apparent on comparison with the other side, allowing for side dominance. A mild flexion contracture, that is, an extension deficit, is possible. Baseball pitchers are most frequently affected. A valgus stress test or milking test must be used to assess medial collateral ligament insufficiency. For possible cubital tunnel syndrome, at least a Tinel sign should be checked, and it should be tested whether elbow hyperextension increases the pain or other symptoms. The shoulder and cervical spine should be examined in addition to the elbow. A tendency toward shoulder subluxation may aggravate golfer’s elbow symptoms; thoracic outlet syndrome and radiculopathies may resemble cubital tunnel syndrome. Soft-tissue calcifications or bony projections (osteophytes) at the medial epicondyle occur in 18% to 25% of patients and are not prognostically relevant. If valgus instability, that is, medial gapping, is known, imaging may be performed in both positions. Ultrasound can show tendon thickening, hypoechogenicity, neovascularization and insertional changes. It is particularly useful when clinical findings are unclear or symptoms are refractory to treatment. One study reports 95% sensitivity and 92% specificity for ultrasound. MRI likewise achieves high diagnostic accuracy and clearly depicts soft-tissue changes, partial and complete tears, and changes such as partial and complete tears of the medial collateral ligament. It should nevertheless be used selectively. It should also show changes at the medial epicondyle, medial collateral ligament or humeroulnar joint.

While the acute condition may still be readily reversible, chronicity may produce a self-reinforcing cycle of pain, faulty loading and tissue changes that can also lead to rest pain and night pain. Unlike RSI, somewhat less frequent but considerably heavier movements are the triggers here; RSI may be triggered by typing on a keyboard or phone or clicking a mouse. Peak occurrence is between 35 and 50 years of age.

In people whose elbow can crack, meaning that a small movement produces a clearly audible crack but subsequent identical movements do not do so for some time, a minor elbow subluxation is presumed. The crack is then the sound produced by reduction. The unreduced state may be associated with greater pain at the muscle origin affected by golfer’s elbow (a sensation of tension at rest and pain on movement or loading).

Causes

  1. Repetitive, forceful loading of the forearm flexors and pronator teres, particularly during gripping, wrist flexion and forearm pronation, can cause microtrauma and tendinopathy at the medial epicondyle. Prolonged pressure in the region of the sulcus ulnaris, for example when leaning on the elbow, may additionally cause or aggravate ulnar nerve irritation.
  2. Mechanical trigger: muscular overload causes microtrauma, for example in golfers or often in manual workers; in sport, faulty technique may also be responsible.

Predisposing factors

  1. Insufficient training and flexibility
  2. Frequent forceful gripping and frequent inward rotation of the forearm under load
  3. Racket sports, particularly with technique errors; climbing; various manual occupations; physical work such as road construction, trades and mechanical work
  4. Side sleeping with a strongly flexed arm supporting the head may aggravate existing ulnar nerve irritation, but has not been demonstrated to be a confirmed risk factor for golfer’s elbow.

Symptoms

  1. Stabbing pain on the inside of the elbow, aggravated by making a fist and by palmar wrist flexion (particularly against resistance), as well as lifting; it may radiate, especially into the forearm
  2. Tenderness of the epicondyle
  3. Slight local swelling at the medial epicondyle may occasionally occur; tenderness is more common.
  4. Painful reduction in strength of the affected muscles

Diagnosis

  1. History
  2. Palpation: induration, increased muscle tone, local tenderness
  3. Increased or earlier stretch pain during dorsiflexion of the hand and fingers
  4. The diagnosis can usually be made from the history and examination
  5. If necessary, X-rays to exclude consequences of fractures; in chronic cases, these may show calcific deposits in the tendon; if necessary, ultrasound to show swelling, or MRI
  6. Tests and signs: reverse Cozen test (tests wrist palmar flexors), medial epicondylitis test (tests wrist palmar flexors), resisted forearm pronation (tests the humeral head of pronator teres), resisted wrist palmar flexion (tests wrist palmar flexors), lifting heavy objects with an underhand grip (tests wrist palmar flexors), elbow extension in supination with the wrist passively dorsiflexed, definite yoga golfer’s elbow test cluster

Complications

  1. Cubital tunnel syndrome: compression of the ulnar nerve (entrapment syndrome) in the sulcus ulnaris at the elbow; also referred to as sulcus ulnaris syndrome.
  2. Chronicity with rest pain, night pain and severe pain triggered by minor stimuli

Treatment

  1. Short-term immobilization (long-term immobilization may promote recurrence); stop or avoid the triggering load
  2. Conservative baseline treatment with load modification, relative unloading, progressive strengthening (isometrics and HSR, heavy slow repetitions) and physiotherapy. During rehabilitation training, unlike sport and everyday activity, pain equivalent to NRS 3 or even NRS 5 may be tolerated if it subsides within 24 hours and does not increase over successive exercise sessions.
  3. Local anesthesia if necessary
  4. A corticosteroid injection may provide short-term pain relief for persistent symptoms. Because of the lack of long-term benefit, potentially higher recurrence rates and the tendency to damage tendon tissue, it should be used only selectively, not repeatedly, and only after an adequate trial of conservative treatment.
  5. In treatment-refractory cases, injectable treatments such as platelet-rich plasma (PRP) or autologous blood may be considered. The evidence is heterogeneous. Botulinum toxin is an option only in individual cases.
  6. Transverse friction massage
  7. NSAIDs
  8. Electrotherapy (TENS: transcutaneous electrical nerve stimulation)
  9. Cryotherapy
  10. Extracorporeal shockwave therapy
  11. Stretching (important)
  12. Physiotherapy after the acute pain has largely subsided
  13. Cooling in the acute phase (do not apply ice directly to the skin); later, warming the muscles
  14. Epicondylitis brace
  15. During immobilization: leave the elbow free
  16. In treatment-refractory cases, surgical procedures or minimally invasive tendon interventions may be considered individually. The choice of procedure depends on the findings, symptoms and treatment goal. Options include transverse incision, longitudinal incision and denervation.
  17. A multimodal approach combining load modification, progressive strengthening, load management and, if necessary, symptomatic measures is the usual conservative treatment pathway.
  18. Recurrence prevention centers on gradual progression of loading, adapted technique and progressively increased strengthening. Stretching and cooling may be used as supplementary symptomatic measures. Intensive static stretching should be avoided unless increased muscle tone or restricted flexibility of the affected muscles can be assumed to be a contributing factor. In sport: optimize technique; where possible, lift more often with an overhand grip (caution: risk of lateral epicondylitis); strengthening, preferably HSR (heavy slow repetitions).

Complementary approaches

  1. Acupuncture
  2. Massage (transverse friction)
  3. Leech therapy
  4. Kinesiology taping
  5. Homeopathy: Arnica, Ruta, Bryonia and others

Differential diagnoses

  1. Bursitis
  2. Osteoarthritis
  3. Tumors
  4. Cervical syndrome
  5. Fibromyalgia
  6. Supinator tunnel syndrome: tenderness on the more radial side of the cubital fossa (radial nerve compression syndrome)
  7. Pronator teres syndrome: compression of the median nerve in the region of pronator teres, typically with palmar forearm pain, tenderness over the median nerve in the cubital fossa and possibly sensory disturbances in the median nerve distribution.

Asana practice and movement therapy

As with all insertion tendinopathies, care must be taken not to provoke pain because, for the time being, any provocation of pain may disrupt healing and thus perpetuate the pain. An exception is the rehabilitative strengthening described in Yogabuch. These exercises are: for forearm-pronation golfer’s elbow: practicing forearm supination and pronation and for wrist-palmar-flexion golfer’s elbow and Finger-flexion golfer’s elbow: practicing wrist palmar flexion and dorsiflexion, with additional radial and ulnar deviation exercises for wrist-palmar-flexion golfer’s elbow if necessary, which are among the most important therapeutic measures. It is therefore very helpful first to determine which type or mixed type of golfer’s elbow is present by testing stretch pain and pain on loading.

For the exercises described, a different approach from the general rule of strictly avoiding the relevant pain may be used: observe how the pain develops during 10 to 30 seconds of isometric contraction. If pain clearly decreases during this interval, this may be practiced up to three times daily, while most rehabilitation training should take place with little or no pain.

An upward-facing dog or downward-facing dog with intensive arm work, as well as transitions between them, would generally be well suited to provoking symptoms. The wrist palmar flexors and finger flexors must therefore not be used to push the body backward. The same applies to many other poses: what is normally desirable, namely creating stability and intensity through the forearm muscles and using them as fully as possible, must be avoided here because the muscles or their insertions are too vulnerable.

Full forearm pronation may also need to be avoided. Instead, functional strengthening exercises that are easy to scale should be performed. These primarily include dumbbell exercises such as biceps curls or palmar flexion. In addition, flexibility and muscle tone must be assessed; the palmar forearm stretch and palmar forearm stretch in upavista konasana are particularly suitable. In the former, the elbow is flexed and becomes more flexed during execution; in the latter, it remains extended throughout, permitting a more intensive stretch. This is because the muscles concerned attach proximal to the elbow at the medial epicondyle of the humerus (hence the name), so its position affects the extent of stretching. Pain at the insertion on the epicondyle should only be approached up to the pain threshold; the muscle bellies themselves may of course register an intense stretching sensation. If pain at the epicondyle in these two poses occurs at a greater angle of wrist dorsiflexion when the fingers are flexed (palm on a block, fingers free), this indicates that flexor carpi ulnaris is substantially, though not necessarily exclusively, responsible for the pain.

Arm balances whose stability depends on the finger flexors, both when performed correctly without gaps under the base of the fingers and when performed incorrectly, should be avoided while epicondylitis persists. A wall-supported handstand and right-angle handstand can be performed without difficulty if the affected muscles are not used. When kicking up into handstand, however, these muscles are important in limiting movement of the shoulders toward the wall. Handstand is therefore probably unsuitable for less experienced practitioners: finding a level of muscle engagement that sufficiently limits shoulder movement toward the wall without provoking epicondylitis pain is likely to be very difficult. Forearm stand, in contrast, can be performed without difficulty or restriction. Ardha vasisthasana and vasisthasana are difficult because stability depends substantially on the affected muscles. Both poses, especially vasisthasana itself, will probably need to be avoided for a prolonged period.

Asanas

ICD

M77.1