How Physiotherapists Treat Golfers Elbow
Golfer's elbow (medial epicondylitis) is not confined to golfers, but occurs in many sportsmen and women, with racquet sports the most common causes. Other sports where golfer's elbow occurs are in bowlers in cricket, archers and weightlifters. This and the more common tennis elbow are tendinopathies, overuse syndromes where there is no significant inflammation but a pathological alteration in the body of the tendon at the painful site.
The medial epicondyle is the bone prominence on the inside of the elbow where the forearm and rotatory muscle originate from. The muscles become tendinous near the bone and the tendon inserts into the bone to anchor the muscles. This area is where the pain occurs.and scientific work has not shown an inflammatory process but degenerative one. As the elbow is stresses by forces which would tend to push the elbow out into "knock elbow", the tendon takes a lot of stress and changes occur.
High stresses occur in the cocking phase of a throw and during the subsequent acceleration, and in the golf swing from high backswing down to near the ball strike. Golfers are more likely to have their dominant hand affected and tennis players who use heavy topspin in their forehands are also more at risk.
Golfer's elbow is not as common as tennis elbow but is the commonest cause of medial elbow pain with about half as many women affected as men. The third to fifth decades of life are the commonest periods for pain onset and 60% of golfer's elbow occurs in the dominant hand. An acute onset of pain is reported in a third of patients, with the other two-thirds developing over a period of time.
Pain and ache over the front of the medial epicondyle is the typical symptom, worse with repeated flexion of the wrist and improved with resting. Shoulder, elbow, forearm or hand pain can occur, with weakness or pins and needles in the lower arm. Physiotherapy examination includes the bony tendon insertions, the elbow joints and the muscles, with palpation of the "funny bone" area behind the elbow where the ulnar nerve lies. Nerve involvement can give weakness in the forearm muscles and sensory symptoms, so an exclusion neurological examination is performed by the physio.
The forearm muscles, which flex the wrist and rotate the forearm, originate in tendon-type tissue at the medial epicondyle, the bony lump on the inside part of the elbow. Due to the lack of inflammation the term tendonitis is not correct and tendinopathy, an internal process of degeneration, is the preferred term. Any activity which pushes the lower arm outwards away from the body, into so-called valgus or "knock elbow", puts extra force on the muscles of the flexor origin which are resisting the movement. The throwing a ball action brings these factors into play, especially cocking the wrist at the start of the movement and the acceleration which follows. Golfers, whose dominant hand is typically affected, engage these stresses from the top of the backswing down to just before ball strike. Heavy topspin tennis players are also more susceptible.
Corticosteroid injections are commonly used for treatment of longer term medial epicondylitis but are more useful early on in the management of golfer's elbow to relieve pain. Laser and shockwave therapy have no good evidence for usefulness. Surgery is only considered once conservative physiotherapy has failed. Surgery is used to debride the abnormal tissue from the affected area and in the cases of nerve involvement to move the ulnar nerve from its groove round to the front of the elbow.