Rheumatology

Golfer's Elbow

Does this patient have golfer's elbow?

Golfer's elbow, or medial epicondylitis, is a tendinopathy of the origin of the flexor/pronator tendons at the elbow.

Presentation

It commonly affects patients in their 30-50's. Patients usually do NOT have a history of trauma, though some may. Despite its name, most patients do not play golf. They complain of pain on the medial aspect of their elbow. This pain is exacerbated by activities that require wrist flexion, or forearm pronation.

Physical exam

Tenderness to palpation over the medial epicondyle is the hallmark of the diagnosis. With the elbow in extension, patients will have pain with passive wrist extension and resisted wrist flexion. They may also have pain with resisted forearm pronation.

Range of motion should also be assessed for elbow flexion, extension, and forearm supination and pronation. Limitations of range of motion may suggest an underlying fracture - and not golfer's elbow.

A good neurologic exam should also be performed, paying particular attention to the median and ulnar nerve distributions. Cubital tunnel syndrome can mimic golfer's elbow. Median nerve entrapment in the pronator is a rare cause of anteromedial elbow pain.

Differential diagnosis

Cubital tunnel syndrome

Entrapment of the ulnar nerve at the elbow. Care must be taken to assess the motor and sensation of the ulnar nerve, and to determine if the patient has a subluxing ulnar nerve. If suspected, EMG's should be performed.

Median nerve entrapment in the pronator

Can mimic anteromedial elbow pain. The pain for this will be more anterior than for golfer's elbow. Patients will also have motor and sensory findings consistent with median nerve neuropathy. If suspected, EMG's should be performed.

Medial collateral ligament injury

Common in throwers. Patients will have pain when a valgus stress is placed on the elbow.

Fractures

Usually associated with a history of trauma. X-rays will be diagnostic.

Physeal (growth plate) injury (little leaguer's elbow)

Common cause of medial elbow pain in skeletally immature throwers. Referral to a pediatric orthopaedic surgeon should be considered when treating a skeletally immature patient with medial elbow pain since physeal injuries and fractures are more common than golfer's elbow in this population.

Bone lesions

Tumors and infections are rare causes of medial elbow pain. Radiographs are often diagnostic.

What tests to perform?

Radiographs

X-rays are usually negative in patients with golfer's elbow. Office x-rays are commonly obtained to rule out other pathology, such as fracture, dislocation, or bone lesion. Occasionally, calcifications can be seen adjacent to the medial epicondyle in chronic cases.

Advanced imaging

Usually not needed in the early stages. If symptoms persist with non-operative management, an MRI is obtained to assess the extent of elbow involvement, and to determine if the tendon is torn from the bone. MRI can also rule out concomitant pathology.

If patients are unable to have an MRI, then an ultrasound can be performed. Ultrasound will not show intra-articular pathology as well as an MRI.

How should patients with golfer's elbow be managed?

First-line treatment - rest, physical therapy, anti-inflammatories, ergometric improvements in work space

Patients should avoid painful activities to allow the tendons to rest and heal. A prescription for physical therapy should include directions for stretching and eccentric training of the flexor tendons around the elbow. Eccentric training is when the muscle is contracting as it is being elongated (i.e. a "negative" repetition). Prescribers should also write "modalities prn" so that the therapist can use ultrasound and iontophoresis with a steroid cream at their discretion. Duration of therapy is 6 weeks to start.

NSAIDs should also be prescribed as long as there are no contraindications.

Workplace modifications should be suggested such that the patient limits the amount of wrist flexion and forearm pronation that is necessary for them to perform their job.

Second-line treatment - steroid injection

If there is no improvement with the first line of treatment, then patients are offered a steroid injection. Preferred injection consists of dexamethasone 4mg (1cc), 0.25% marcaine (1cc), 1% lidocaine (1cc) - for a total mixture of 3cc's.

Injection is placed at the site of maximal tenderness taking care to avoid the ulnar nerve if is subluxed anterior to the medial epicondyle. The injection should go around the tendon, not into the tendon. This is accomplished by inserting the needle into the tendon, then gently pushing down on the plunger while pulling the needle back. As soon as minimal resistance is felt on the plunger, then the needle is adjacent to the tendon and the contents of the injection can be delivered.

After the injection, patients are instructed to place ice on the site of injection, and to rest it completely for 1 week. After 1 week, they may resume physical therapy.

Last-line treatment - surgery

If patients are still having symptoms after 6 months of non-operative treatment including physical therapy, anti-inflammatories, and injections, then surgery can be considered. There are several surgical techniques, but the principle of each is debridement of the pathologic portion of the tendon.

Controversies in treatment - platelet-rich plasma (PRP)

PRP has not been well studied for golfer's elbow, but there is growing evidence that it may be beneficial for tennis elbow. However, this procedure is typically not covered by insurers since it is still considered experimental.

What happens to patients with golfer's elbow?

The vast majority of patients (90%) respond well to non-operative treatment and make a full recovery.

How to utilize team care?

Specialty consultations

An orthopaedic surgeon should be consulted if the patient has no resolution of symptoms after 6 months of non-operative treatment as outlined above. They should also be consulted if there are any questions in terms of the diagnosis.

Physical or occupational therapists

PT or OT can both treat this condition. Their role is crucial to treatment.

Are there clinical practice guidelines to inform decision making?

There is very little in the literature regarding the treatment of golfer's elbow. Many of the treatment recommendations are extrapolated from studies on tennis elbow.

What is the evidence?

Ciccotti, MG, Ramani, MN. "Medial epicondylitis". Tech Hand Up Extrem Surg.. vol. 7. 2003 Dec. pp. 190-6.

Nirschl, RP, Rodin, DM, Ochail, DH, Maartmann-Moe, C. "DEX-AHE-01-99 Study Group: Iontophoretic administration of dexamethasone sodium phosphate for acute epicondylitis. A randomized, double-blinded, placebo-controlled study". Am J Sports Med. vol. 31. 2003 Mar-Apr. pp. 189-95.

Stahl, S, Kaufman, T. "The efficacy of an injection of steroids for medial epicondylitis. A prospective study of sixty elbows". J Bone Joint Surg. vol. 79-A. 2997 Nov. pp. 1648-52.

Kurvers, H, Verhaar, J. "The results of operative treatment of medial epicondylitis". J Bone Joint Surg.. vol. 77-A. 1995 Sep. pp. 1374-9.

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