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GOLFER'S ELBOW (MEDIAL EPICONDYLITIS)

Introduction

Medial epicondylitis is a repetitive motion disorder involving wrist flexion or forearm pronation. It is common among baseball pitchers and golfers, as well as those who participate in racquet sports and football and in occupations such as carpentry and plumbing. The repetitive activity causes microtrauma to the flexor-pronator mass, including the pronator teres (PT) and flexor carpi radialis (FCR). Owing to its close proximity to these muscles, the ulnar nerve often becomes irritated.

Related Anatomy

  • PT
  • FCR
  • Flexor digitorum superficialis
  • Palmaris longus
  • Flexor carpi ulnaris
  • Ulnar nerve

Pathophysiology

  • Mictrotrauma

Incidence and Related Conditions

  • Affects men and women equally
  • Affects dominant extremity in 75% of cases
  • Five times less prevalent than lateral epicondylitis (tennis elbow)
  • Frequently associated with ulnar neuropathy and ulnar collateral ligament insufficiency

Differential Diagnosis

  • Cubital tunnel syndrome
  • Ulnar collateral ligament insufficiency
  • Medial collateral ligament injury
Clinical Presentation Photos and Related Diagrams
  • Palpating Medial Epicondyle for tenderness. (Hover over right edge to see more images)
    Palpating Medial Epicondyle for tenderness. (Hover over right edge to see more images)
  • Palpating the flexor origin at the anterior medial epicondyle for tenderness while resisting the patient's active wrist palmar flexion. (Hover over right edge to see more images)
    Palpating the flexor origin at the anterior medial epicondyle for tenderness while resisting the patient's active wrist palmar flexion.
Symptoms
Pain on the inside of the elbow
Elbow stiffness in morning
Night pain on medial side of elbow
Typical History

A 53-year-old right-handed male golfer is complaining of pain on the medial aspect of his right elbow.  He has been preparing for his club tournament and has been at the driving range for 2-4 hours a day for the last three weeks.  He has some night discomfort and the elbow is stiff in the morning.

Positive Tests, Exams or Signs
Range of Motion: Active
Range of Motion: Passive
Tenderness
Work-up Options
Magnetic resonance imaging - MRI without contrast
Sonographic studies - Ultrasound
Radiology studies - X-ray
Images (X-Ray, MRI, etc.)
  • In golfer's elbow the X-ray of the elbow is usually normal. Occasion calcifications of the flexor origin will be seen.
    In golfer's elbow the X-ray of the elbow is usually normal. Occasion calcifications of the flexor origin will be seen.(Hover over right edge to see more images)
  • Normal elbow MRI
    Normal elbow MRI
  • Medial epicondylitis with 1-subcutaneous edema; 2- tendinopathy; 3- edema in medial epicondylar bone
    Medial epicondylitis with 1-subcutaneous edema; 2- tendinopathy; 3- edema in medial epicondylar bone
Treatment Options
Conservative: 
  • First-line treatments: rest, ice, modification of activities, physical therapy, counterforce bracing, NSAIDS, ultrasound, corticosteroid injections
  • Platelet Rich Plasma (PRP) Injections
  • Follow-up: Guided rehabilitation and return to sports
Operative: 
  • Indication: when pain limits function and interferes with daily activities/work; when conservative approaches for up to 6 months fail
  • Procedure: open debridement of PT/FCR, reattachment of flexor-pronator mass

−     Excision of pathological tissue

−     Enhancement of vascular environment

−     Reattachment of flexor-pronator mass to medial epicondyle

Complications
  • Medial antebrachial cutaneous neuropathy from avulsion or transection
Outcomes
  • Surgical success rates are 80–95%.
Key Educational Points
  • Golfer's elbow is an overuse syndrome of the dominant trailing arm caused by repetitive tension overloading of the flexor-pronator muscle at or near it's insertion on the medial epicondyle
  • Atheletes complain of medial and proximal forearm pain aggravated by golfing, curling and throwin curve balls.
  • Diagnosis can be confirmed by reproducing the pain with resisted wrist flexion and forearm pronation.
Practice and CME
References

New articles

  1. Glanzmann MC, Audigé L. Efficacy of platelet-rich plasma injections for chronic medial epicondylitis. J Hand Surg Eur 2015 ePub. PMID: 25600853
  2. Kwon BC, Kwon YS, Bae KJ. The Fascial Elevation and Tendon Origin Resection Technique for the Treatment of Chronic Recalcitrant Medial Epicondylitis. Am J Sports Med 2014;42(7):1731-1737. PMID: 24758782

Reviews

  1. Hoogvliet P, et al. Does effectiveness of exercise therapy and mobilisation techniques offer guidance for the treatment of lateral and medial epicondylitis? A systematic review. Br J Sports Med 2013;47(17):1112-9. PMID: 23709519
  2. Shiri R, Viikari-Juntura E. Lateral and medial epicondylitis: role of occupational factors. Best Pract Res Clin Rheumatol 2011;25(1):43-57. PMID: 21663849

Classics

  1. Lapidus PW, Guidotti FP. Lateral and medial epicondylitis of the humerus. IMS Ind Med Surg 1970;39(4):171-3. PMID: 5267108
  2. Vangsness CT Jr, Jobe FW. Surgical treatment of medial epicondylitis. Results in 35 elbows. J Bone Joint Surg Br 1991;73(3):409-11. PMID: 1670439