Golfer's Elbow (Medial Epicondylitis)
Summary
Medial Epicondylitis ("Golfer's Elbow") is a degenerative overuse tendinopathy of the Common Flexor Origin at the medial aspect of the elbow. It is 5 to 7 times less common than Lateral Epicondylitis (Tennis Elbow). While often self-limiting, it can be notoriously resistant to treatment and is frequently associated with ulnar neuropathy due to anatomical proximity. [1,2]
Anatomy
- Origin: Medial Epicondyle of Humerus.
- Muscles: Pronator Teres and Flexor Carpi Radialis (FCR) are the primary pathological sites. (Others: Palmaris Longus, Flexor Carpi Ulnaris).
- Nerve: The Ulnar Nerve runs in the cubital tunnel immediately posterior to the medial epicondyle.
Clinical Pearls
The "Golfer" Misnomer: Over 90% of cases are NOT related to golf. It is common in carpenters (hammering), plumbers, and throwing athletes (valgus stress).
Neuritis Association: Up to 20% of patients have co-existing Ulnar Neuritis (Cubital Tunnel Syndrome). Always ask about tingling in the little finger. If present, be extremely cautious with steroid injections (risk of nerve injury).
The Valgus Overload: In overhead throwing athletes (pitchers/cricketers), medial elbow pain is often NOT simple epicondylitis but an injury to the Ulnar Collateral Ligament (UCL). This requires an MRI and possibly reconstruction ("Tommy John Surgery").
Demographics
- Age: 30-50 years.
- Gender: Male = Female.
- Incidence: 0.4% of population (vs 1-3% for Tennis Elbow).
Mechanism
- Overuse: Repetitive wrist flexion and forearm pronation leads to micro-tears in the tendon origin.
- Histology: It is NOT an inflammatory condition ("-itis" is wrong). It is a tendinosis: Angiofibroblastic Hyperplasia. Disorganized collagen, neovascularisation, and lack of inflammatory cells.
- Healing: The poor blood supply at the enthesis (bone-tendon junction) prevents adequate healing, leading to chronic degeneration.
Symptoms
Signs
- Look: Usually normal. Muscle wasting?
- Feel: Tenderness over CFO. Tinel's test over cubital tunnel.
- Move:
- Golfer's Elbow Test: Elbow extended, forearm supinated, wrist extended (stretches flexors). Pain = Positive.
- Valgus Stress Test: At 30° flexion (tests UCL).
Imaging
- X-Ray: Usually normal. May show calcification in tendon (20%). Rule out OA.
- Ultrasound: Shows tendon thickening, hypoechoic areas, and neovascularisation (Doppler flow).
- MRI: Gold standard. Reserved for failed conservative management or suspected UCL injury.
Management Algorithm
MEDIAL ELBOW PAIN
↓
CLINICAL DIAGNOSIS CONFIRMED
(Exclude Cervical Radiculopathy
and Cubital Tunnel Syndrome)
↓
CONSERVATIVE CARE (First Line)
- Activity Modification (Stop throwing)
- NSAIDs (Gel/Oral)
- Physiotherapy (Eccentric Loading)
- Epicondylitis Clasp (Brace)
↓
NO IMPROVEMENT
(After 6 months)
↓
INTERVENTIONAL
- Nitroglycerin Patches (Topical NO)
- Shockwave Therapy (ESWT)
- PRP Injection (?)
- Steroid Injection (CAUTION)
↓
SURGERY
(Last Resort)
- Debridement of CFO
Specific Treatments
- Physiotherapy: The mainstay. Eccentric Loading (strengthening the muscle while it lengthens) stimulates collagen remodeling.
- Corticosteriod Injection: Provides short-term relief (4-6 weeks) but worsens long-term outcomes (recurrence). Risk of fat atrophy and skin depigmentation.
- Surgery: Indicated if >6-12 months of failed care. Success rate ~80%.
- Ulnar Neuropathy: Compression or irritation.
- Rupture: Spontaneous rupture of the flexor origin (rare, usually after steroid injection).
- Chronic Pain: 10% refractory to all treatment.
- Natural History: Self-limiting. Most resolve in 6-18 months even without treatment.
- Recurrence: Common if activity is not modified.
Key Guidelines
| Guideline | Organisation | Key Recommendations |
|---|---|---|
| Tendinopathy | NICE CKS | Conservative management is superior long term. Avoid repeated steroids. |
| Comparison | AAOS | Supports eccentric exercise over passive modalities (ultrasound/laser). |
Landmark Evidence
1. Steroid vs Placebo vs Physio
- Several RCTs (e.g., Coombes et al) in tennis/golfer's elbow show that while steroids give rapid relief at 4 weeks, at 1 year the steroid group performs worse than the placebo/"wait and see" group.
What is Golfer's Elbow?
It is a wear-and-tear condition of the tendon on the inside of your elbow. This tendon attaches the muscles that bend your wrist. It is caused by repetitive gripping or twisting.
Why does it hurt?
The tendon fibres have been strained and have developed tiny microscopic tears. Instead of healing properly, the tissue has become scarred and unhealthy.
How do we fix it?
It takes time. The most effective treatment is persistent, specific exercises (eccentric loading) that strengthen the tendon. A strap can help take the load off.
Can I have an injection?
We try to avoid steroid injections now. They take the pain away quickly, but they weaken the tendon and make it more likely to come back worse later.
Primary Sources
- Amin NH, et al. Medial Epicondylitis: Evaluation and Management. J Am Acad Orthop Surg. 2015.
- Coombes BK, et al. Efficacy and safety of corticosteroid injections and other injections for management of tendinopathy: a systematic review of randomised controlled trials. Lancet. 2010.
Common Exam Questions
- Anatomy: "Common Flexor Origin muscles?"
- Answer: Pronator Teres, FCR, Palmaris Longus, FCU.
- Test: "Resisted movement?"
- Answer: Flexion of wrist / Pronation of forearm.
- Complication: "Nerve risk?"
- Answer: Ulnar nerve (Cubital tunnel).
- Pathology: "Inflammatory cells present?"
- Answer: No (It is Angiofibroblastic Hyperplasia).
Viva Points
- Medial Apophysitis: In children (Little League Elbow), the growth plate is pulled off. This is NOT simple tendonitis. Requires strict rest to prevent growth arrest.
- Golf Swing: It affects the Trailing Arm (Right arm in a right-handed golfer) during the downswing (flexion/pronation moment). Tennis elbow affects the Leading Arm.
Medical Disclaimer: MedVellum content is for educational purposes and clinical reference. Clinical decisions should account for individual patient circumstances. Always consult appropriate specialists.