Medial epicondylitis A.K.A Golfer's elbow
What is medial epicondylitis?
Medial epicondylitis, also known as Golfer’s elbow, is mostly an overload injury to the inner forearm tendons that leads to an inflammatory condition called a tendinopathy. The most sensitive region is located along the elbow near the origin of the wrist flexors on the medial epicondyle of the humerus. Due to injury or chronic overuse, the tendons that attach the flexor muscles to the humerus become irritated causing swelling and pain. When compared to Tennis elbow/Lateral epicondylitis; Golfer's elbow has a lower incidence. Even though it is known as Golfer's elbow 90% to 95% of all cases do not involve sports participation. Occupations such as carpentry, plumbing and meat cutting have been implicated because of the chronic repetitive contractile loading of the wrist flexor and pronator muscles.
Causes and Risk factors
Medial epicondylitis is caused when too much force is used to bend the wrist toward the palm of the forearm. This can happen when swinging a golf club or pitching a baseball. Other possible causes of the condition can be serving with great force in tennis or frequent use of other hand tools on a continuous basis. Weak shoulder muscles or wrist muscles can make the patient susceptible to developing the condition.
Some known risk factors are:
- Excess weight: The excess weight causes tendon overload and also increases the production of pro-inflammatory mediators.
- Smoking: Smoking may interfere with the vascular circulation to tendons, which not only places these tissues at risk for injury but also slows or prevents their healing during a recovery period. Former smokers are also at higher risk of epicondylitis because previous exposure to tobacco may have persistent effects on the vascular system.
- Diabetes Mellitus: Diabetic patients are at higher risk for these tendon conditions because of the inflammation that is consistent with high blood sugar levels and the negative effect it has in decreasing blood flow to the tendons accelerating the damage.
Clinical presentation
The most common symptom of medial epicondylitis is pain and tenderness located along the palm side of the forearm extending from the elbow to the wrist on the ulnar side (same side as the little finger). Other possible findings are weakness at the hands and wrist or sensation of numbness and tingling that radiate into one or more fingers (usually the ring and little finger) due to ulnar nerve irritation. The elbow may feel stiff, and making a fist might hurt. The pain can be aggravated by bending the wrist toward the palm against resistance and by pronation.
What to expect at the doctor's office?
To achieve a diagnosis the physician will complete a physical examination, which may include applying pressure to the elbow, wrist, and fingers to check for stiffness or discomfort. The more common physical exams performed are the passive technique and the active technique.
During the passive technique the patient can be seated or standing, for the exam the physician first palpates the medial epicondyle while supporting the elbow with one hand, and with the other hand passively supinates the patient’s forearm and fully extends the elbow, wrist and fingers. If sudden pain or discomfort is reproduced along the medial aspect of the elbow in the region of the medial epicondyle, then this test is considered positive. For the active technique the patient needs to be seated with the elbow flexed and the forearm placed palm up (forearm supination); the examiner then grasps the patient’s wrist and elbow and attempts to straighten out the elbow (forced extension) against the patient’s resistance (resisted elbow-wrist flexion). If sudden pain or discomfort is reproduced along the medial aspect of the elbow in the region of the medial epicondyle, then this test is considered positive.
An X-ray can help the doctor rule out other causes of elbow pain, such as a fracture or arthritis. Rarely, more comprehensive imaging studies such as MRI or CT scans need be performed to asses injuries to tissues.
Treatment options
Conservative options:
Most cases may resolve without intervention. Persistent symptoms can be treated by:
- Rest: Repeatedly using the affected arm can prolong healing and worsen your symptoms. Stop activities that involve repetitive movements until the pain disappears. Once the pain disappears, gradually ease back into activities to avoid re-injuring yourself.
- Ice or a cold compress: The cold help reduce swelling, pain, and inflammation.
- Over-the-counter (OTC) medication (i.e. Ibuprofen/Advil and Acetaminophen/Tylenol): Help reduce swelling and inflammation.
- Steroid Injections: Depending on the severity of pain, the doctor may recommend a steroid injection.
- Stretching exercises: If the patient have weakness or numbness, they may be a suitable candidate for physical therapy.
- Wearing a brace/Elastic bandage around the elbow: This can reduce tendinitis and muscle strain.
Most cases will improve with OTC medication and home remedies. If your signs and symptoms don't respond to conservative treatment in six to 12 months, surgery might be an option.
Surgical option:
This surgery is known as an open medial epicondylar release. The goal of the surgery is to remove the damaged tendon that's causing pain. During the procedure, a surgeon makes an incision in the forearm, cuts the tendon, removes the damaged tissues around the tendon, and then reattaches a healthy tendon in its place. After the healthy tendon is placed the surgeon closes the incision with stitches and applies a bandage. After surgery the arm is put in a soft dressing to limit movements during the first week of recovery; this gives the tendon a chance to heal. At a follow-up appointment in about 10 days, the doctor can remove the stitches and check progress. The patient may get a referral to physical therapy where they can work on strengthening the elbow. Therapy may be needed for two to three months. It can take up to six months to get back to sports and other high-level activities.
Everyone recovers from injury at a different rate so return to your sport or activity will be determined by how soon the elbow recovers and not by how many days or weeks it has been.
How can I prevent it?
You can take these steps as a prevention to developing medial epicondylitis:
- Strengthen your forearm muscles
- Stretch before your activity
- Use the right equipment (golf club not too heavy or racket not too small)
- Lift properly by keeping the wrists rigid and stable to reduce the force to your elbow
- Know when to rest