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Golfer's elbow, or medial epicondylitis, is tendinosis (or more precisely
enthesopathy An enthesopathy refers to a disorder involving the attachment of a tendon or ligament to a bone. This site of attachment is known as the entheses, enthesis (pl. entheses). If the condition is known to be Inflammation, inflammatory, it can more pr ...
) of the medial common flexor tendon on the inside of the
elbow The elbow is the region between the upper arm and the forearm that surrounds the elbow joint. The elbow includes prominent landmarks such as the olecranon, the cubital fossa (also called the chelidon, or the elbow pit), and the lateral and t ...
. It is similar to
tennis elbow Tennis elbow, also known as lateral epicondylitis is an enthesopathy (attachment point disease) of the origin of the extensor carpi radialis brevis on the lateral epicondyle.  It causes pain and tenderness over the bony part of the lateral epi ...
, which affects the outside of the elbow at the lateral epicondyle. The tendinopathy results from overload or repetitive use of the arm, causing an injury similar to ulnar collateral ligament injury of the elbow in "pitcher's elbow".


Description

The anterior-medial forearm contains several muscles that flex the wrist and
pronate Motion, the process of movement, is described using specific anatomical terms. Motion includes movement of organs, joints, limbs, and specific sections of the body. The terminology used describes this motion according to its direction relativ ...
the forearm. These muscles have a common tendinous attachment at the
medial epicondyle of the humerus The medial epicondyle of the humerus is an epicondyle of the humerus bone of the upper arm in humans. It is larger and more prominent than the Lateral epicondyle of the humerus, lateral epicondyle and is directed slightly more posteriorly in the ...
at the elbow joint. The flexor and pronator muscles of the forearm include the pronator teres,
flexor carpi radialis In anatomy, flexor carpi radialis is a muscle of the human forearm that acts to flex and (radially) abduct the hand. The Latin ''carpus'' means wrist; hence flexor carpi is a flexor of the wrist. Origin and insertion The flexor carpi radialis is ...
, palmaris longus, and flexor digitorum superficialis, all of which originate on the medial epicondyle and are innervated by the
median nerve The median nerve is a nerve in humans and other animals in the upper limb. It is one of the five main nerves originating from the brachial plexus. The median nerve originates from the lateral and medial cords of the brachial plexus, and has cont ...
. The
flexor carpi ulnaris muscle The flexor carpi ulnaris (FCU) is a skeletal muscle, muscle of the forearm that flexion, flexes and Adduction, adducts at the wrist joint. Structure Origin The flexor carpi ulnaris has two heads; a humeral head and ulnar head. The humeral head o ...
also inserts on the medial epicondyle and is innervated by the
ulnar nerve The ulnar nerve is a nerve that runs near the ulna, one of the two long bones in the forearm. The ulnar collateral ligament of elbow joint is in relation with the ulnar nerve. The nerve is the largest in the human body unprotected by muscle or ...
. Together, these five muscles have a common attachment (an enthesis) on the medial epicondyle of the humerus. The flexor tendon is approximately long, crosses the medial aspect of the elbow, and runs parallel to the ulnar collateral ligament. The injury is not acute
inflammation Inflammation (from ) is part of the biological response of body tissues to harmful stimuli, such as pathogens, damaged cells, or irritants. The five cardinal signs are heat, pain, redness, swelling, and loss of function (Latin ''calor'', '' ...
, but rather is a chronic disorder resulting from overuse of a repetitive arm motion. Repetitive activity leads to recurrent microtears within the flexor tendon, with remodeling of the
collagen Collagen () is the main structural protein in the extracellular matrix of the connective tissues of many animals. It is the most abundant protein in mammals, making up 25% to 35% of protein content. Amino acids are bound together to form a trip ...
fibers and an increase in the amount of mucoid
ground substance Ground substance is an amorphous gel-like substance in the extracellular space of animals that contains all components of the extracellular matrix (ECM) except for fibrous materials such as collagen and elastin. Ground substance is active in the d ...
. As a result, scar tissue formation and thickening of the tendon lead to reduced collagen strength and pain with repetitive use.


Causes

The condition is referred to as ''golfer's elbow'' when a full golf swing causes elbow pain. It may also be called ''pitcher's elbow'' due to the same tendon being stressed by repetitive throwing of objects, such as a baseball or
football Football is a family of team sports that involve, to varying degrees, kick (football), kicking a football (ball), ball to score a goal (sports), goal. Unqualified, football (word), the word ''football'' generally means the form of football t ...
. Golfer's elbow appears to occur from repetitive full swings during the period from the top of the backswing to just before ball impact. The full swing motion causes high energy valgus forces during the late cocking (backswing in golf) and acceleration phase (downswing and impact). It is unknown whether this condition is any more common in labor-related occupations with forceful repetitive activities (such as in construction or plumbing) than it is in the general public. In adults, the pathophysiology may involve mucoid degeneration (disorganized collagen, increased extra-cellular matrix, and chondroid metaplasia).


Diagnosis

Medial epicondylitis is diagnosed based on characteristic pain with activities using strength in wrist flexion and confirmed on examination with discrete point tenderness over the common flexor origin at the medial epicondyle, and pain with resisted wrist flexion and passive wrist extension. Imaging may be employed, although radiography might show calcifications in the muscle origin.
Ultrasound Ultrasound is sound with frequency, frequencies greater than 20 Hertz, kilohertz. This frequency is the approximate upper audible hearing range, limit of human hearing in healthy young adults. The physical principles of acoustic waves apply ...
and
magnetic resonance imaging Magnetic resonance imaging (MRI) is a medical imaging technique used in radiology to generate pictures of the anatomy and the physiological processes inside the body. MRI scanners use strong magnetic fields, magnetic field gradients, and ...
can identify the mucoid degeneration, but are not necessary for diagnosis.


Occurrence

Medial injury of the flexor tendon is estimated to occur in 0.4% of the population. It occurs most often in people ages 45 to 64, is more common in women than in men, and with 75% of cases in the dominant arm.
Risk factor In epidemiology, a risk factor or determinant is a variable associated with an increased risk of disease or infection. Due to a lack of harmonization across disciplines, determinant, in its more widely accepted scientific meaning, is often use ...
s for developing golfer's elbow include improper technique or lack of strength, endurance, or flexibility. Risk factors in people performing manual labor include heavy and excessive repetition, high
body mass index Body mass index (BMI) is a value derived from the mass (Mass versus weight, weight) and height of a person. The BMI is defined as the human body weight, body mass divided by the square (algebra), square of the human height, body height, and is ...
, the presence of comorbidities, and high work demands.


Treatment

Non-specific treatments include: *
Non-steroidal anti-inflammatory drug Non-steroidal anti-inflammatory drugs (NSAID) are members of a therapeutic drug class which reduces pain, decreases inflammation, decreases fever, and prevents blood clots. Side effects depend on the specific drug, its dose and duration of ...
s (NSAIDs):
ibuprofen Ibuprofen is a nonsteroidal anti-inflammatory drug (NSAID) that is used to relieve pain, fever, and inflammation. This includes dysmenorrhea, painful menstrual periods, migraines, and rheumatoid arthritis. It can be taken oral administration, ...
,
naproxen Naproxen, sold under the brand name Aleve among others, is a nonsteroidal anti-inflammatory drug (NSAID) used to treat pain, menstrual cramps, and inflammatory diseases such as rheumatoid arthritis, gout and fever. It is taken orally. It ...
or
aspirin Aspirin () is the genericized trademark for acetylsalicylic acid (ASA), a nonsteroidal anti-inflammatory drug (NSAID) used to reduce pain, fever, and inflammation, and as an antithrombotic. Specific inflammatory conditions that aspirin is ...
* Heat or ice * A counterforce brace or "elbow strap" to reduce strain at the elbow epicondyle, to limit pain provocation and to protect against further damage. Before anesthetics and steroids are used, conservative treatment with an occupational therapist may be attempted. Before therapy can commence, treatment such as rest, ice, compression and elevation (R.I.C.E.) will typically be used. This will help to decrease the pain and inflammation; rest will alleviate discomfort because golfer's elbow is an overuse injury. The subject can use a tennis elbow splint for compression. A pad can be placed anteromedially on the proximal forearm. The splint is made in 30–45 degrees of elbow flexion. A daytime elbow pad also may be useful, by limiting additional trauma to the nerve. Simple analgesic medication has a place, as does more specific treatment with oral
anti-inflammatory Anti-inflammatory is the property of a substance or treatment that reduces inflammation, fever or swelling. Anti-inflammatory drugs, also called anti-inflammatories, make up about half of analgesics. These drugs reduce pain by inhibiting mechan ...
medications. These will help control pain and any inflammation. A more invasive treatment is the injection into and around the inflamed and tender area of a
glucocorticoid Glucocorticoids (or, less commonly, glucocorticosteroids) are a class of corticosteroids, which are a class of steroid hormones. Glucocorticoids are corticosteroids that bind to the glucocorticoid receptor that is present in almost every vertebra ...
(
steroid A steroid is an organic compound with four fused compound, fused rings (designated A, B, C, and D) arranged in a specific molecular configuration. Steroids have two principal biological functions: as important components of cell membranes t ...
) agent.


Physical therapy

Therapy includes a variety of exercises for muscle and tendon reconditioning, starting with stretching and gradual strengthening of the flexor-pronator muscles. Strengthening will slowly begin with isometrics and progresses to eccentric exercises helping to extend the range of motion back to where it once was. After the strengthening exercises, it is common for the subject to ice the area. * Kinesiology Taping(KT) is a way to aid in the treatment of golfer's elbow. KT is meant to mimic the skins elasticity, allowing for muscle support without restriction of range of motion. Introducing it has shown effects of improving sensory feedback and the force sense accuracy of patients. Improving force sense accuracy can help with the gripping of objects while improving sensory feedback can help with muscle control and reducing strain. Together, these improvements can enhance overall muscle activation, reduce pain and support the tendon's affected at the elbow. Taping can be used supplementally with other modes of therapy to allow for greater gains. * Ultrasound Guided Platelet-Rich Plasma (PRP) Injections- While ultrasound-guided PRP injections are increasingly being used in clinical practice, a systemic review found no significant differences in pain relief or functional improvements compared to control treatments for lateral and medial epicondylitis. Patients also reported feeling pain at the PRP injection site. The effectiveness of PRP injections remain uncertain at this point, and more studies are needed.


Surgery

After 6 months if the symptoms do not improve, surgery may be recommended. Surgical debridement or cleaning of the area is one of the most common treatments. The ulnar nerve may also be decompressed surgically. If the appropriate remediation steps are taken – rest, ice, and rehabilitative exercise and stretching – recovery may follow. Few subjects will need to progress to steroid injection, and less than 10% will require surgical intervention. Arthroscopy is not an option for treating golfer's elbow.


See also

* Radial tunnel syndrome *
Repetitive strain injury A repetitive strain injury (RSI) is an injury to part of the musculoskeletal or nervous system caused by repetitive use, vibrations, compression or long periods in a fixed position. Other common names include repetitive stress injury, repetitiv ...
*
Tennis elbow Tennis elbow, also known as lateral epicondylitis is an enthesopathy (attachment point disease) of the origin of the extensor carpi radialis brevis on the lateral epicondyle.  It causes pain and tenderness over the bony part of the lateral epi ...


References

{{Occupational safety and health Golf terminology Occupational diseases Overuse injuries Soft tissue disorders Sports injuries Golf culture