Golfer’s Elbow Medial epicondylitis
Danielle R. Steilen-Matias, MMS, PA-C
Medial epicondylitis or “Golfer’s elbow” is a form of tendonitis, affecting the tendons, which are the ends of muscles that attach to bone. The medical name, medial epicondylitis, comes from the names of the bony prominences where the tendons insert, and where the painful inflammation occurs.
By far the most common cause of golfer’s elbow is overuse of the muscles that are attached to the bone at the elbow. Any action that places a repetitive and prolonged strain on the forearm muscles, coupled with inadequate rest, will tend to strain and overwork those muscles. This injury is not only common is golfers but in the workplace as well.
Doctors in France writing in the medical literature give a good summation of this problem:
- medial epicondylitis is often manifested in a professional or in a sport context leading to repetitive wrist movements.
- The diagnosis is primarily made by a doctor during an examination. Additional tests such as X-ray or MRI are indicated when the doctor cannot isolate medial epicondylitis as the problem and is searching for differential diagnoses.
- There is no consensus on treatment.
- After a period of rest, stretching then strengthening exercises are recommended.
- Corticosteroid injections may provide a short-term beneficial effect. (see below)
- Platelet-Rich Plasma injections have recently gained popularity as an effective treatment..
- In case of failure of treatment, surgery is possible, but only in a minority of patients.1
In other research, laser or radiofrequency microtenotomy for elbow epicondylitis surgery to cut the tendon was recommended in difficult cases.2
Physical examination will benefit the patient with elbow problems more than a diagnosis based soley on MRI
In a May 2017 article, doctors at the Department of Orthopedic Surgery, New York Presbyterian/Columbia University Medical Center discussed the over reliance of technological assessment of (MRIs/Scans) in helping to determine diagnosis and treatment in problems of elbow tendinopathy.
Writing in the The Physician and sportsmedicine, the doctors noted:
“With increased participation in overhead sports in an aging population, the incidence of elbow injuries has risen. A comprehensive knowledge of elbow anatomy and biomechanical function of the elbow complex is prerequisite in the assessment of patients with elbow injuries; however, a thorough understanding of alternative and confounding pathologies is essential for accurate diagnosis.”
Stopping here for a note on this statement. The study says: “alternative and confounding pathologies.” That is problems surrounding and in the elbow joint not limited to a single diagnosis, in other words the whole elbow joint needs to be examined to assess treatment.
Returning to the research:
“Because tendinopathy, tendonitis, and tendon tears have an anatomic basis for their pathology, a targeted history and meticulous physical examination often yields an accurate clinical diagnosis. The importance of physical examination and provocative examination maneuvers must be stressed in a technologically advanced era where clinical diagnosis is too commonly attained solely by advanced imaging modalities.”
Stopping here for a note on this statement. The study says: “physical examination and provocative examination maneuvers.” That is the recreation of the pain stimulus in the elbow by palpation and rotating the elbow.
Back to the study, the doctors note in summation:
“A revived dedication to the physical examination may enhance our ability to correctly diagnose various pathologies about the elbow. Early and accurate clinical diagnosis is the first step in the proper initiation of treatment modalities and improvement in overall patient outcome.”3
In a study discussed at greater length in our article on the problems of tennis elbow, University medical researchers in Italy published their findings under the title :”It’s time to change perspective! New diagnostic tools for lateral elbow pain.” This is an August 2017 publication date. The Italian team is saying what the Columbia University researchers are saying elbow pain is a whole joint disease, you must treat the whole elbow.
Here are the brief notes from the study in the journal Musculoskeletal surgery.
The presence of intra-articular findings (problems within the elbow) that may complement the extra-articular pathology (problems from around the elbow) in lateral epicondilytis has been suggested, and a role for minor instability of the elbow as part of the causative process of this disease has been postulated.(Our note: This paper is acknowledging that elbow instability does play a role in the cause of “tennis elbow”.)
So the Italian team devised two new tests aimed at detecting intra-articular pathology in patients affected by recalcitrant lateral epicondylitis and investigate their diagnostic performance. (They are going to find where the instability comes from).
- Supination and Antero-Lateral pain Test (SALT);
- Posterior Elbow Pain by Palpation-Extension of the Radiocapitellar joint (PEPPER).
SALT moves the elbow around trying to get the “jump” or pain response.
PEPPER palpates the elbow – presses down on spots looking for the jump response.
- In 90% of the patients, at least one test was positive. All patients with signs of lateral ligamentous patholaxity (ligament laxity of weakness) or intra-articular abnormal findings had a positive response to at least one of the two tests.
The two new diagnostic tests (SALT and PEPPER) were specifically designed to evoke pain from intra-articular structures. These tests could be a valid support in the diagnostic algorithm of recalcitrant lateral elbow pain. Positive findings may be indicative of a minor instability of the lateral elbow condition. 4
Medial epicondylitis treatments
Typical for elbow pain, especially if it is the result of sports or athletic activities, involves RICE treatment (Rest, Ice, Compression and Elevation). Application of a brace, splint or cast may also be advised. The problem with this treatment approach is that it decreases inflammation (inflammation heals!) at a time when the injured area needs it most, resulting, unfortunately, in decreased healing.
It has been observed that most athletes who excel in their careers have had at least one cortisone shot in their elbows. In fact, steroid injections and anti-inflammatory medications are yet another standard practice for chronic elbow pain.
However, in the long run, these treatments do more damage than good. Although cortisone shots and anti-inflammatory drugs have been shown to produce short-term pain benefit, both result in long-term loss of function and even more chronic pain by actually inhibiting the healing process of soft tissues.
Spanish and Italian researchers writing in the medical journal Expert opinion in drug safety write of these concerns in new research from March 2017:
- “local glucocorticoids injections are widely administered for the treatment of tendinopathies. positive results have been observed in some tendinopathies but not in others. moreover, worsening of symptoms, and even spontaneous tendon ruptures has been reported.
- Several experimental studies suggest that the direct action of glucocorticoids on tendons is detrimental. Loss of collagen organization, impaired viability of fibroblasts (cells that contribute to healing by stimulating collagen production and extracellular matrix), depletion of stem cells pool, and reduced mechanical properties have been observed.”5
Prolotherapy offers a highly successful treatment option for golfer’s elbow. Chronic pain is most commonly due either to cartilage deterioration, or to tendon and ligament weakness, as is the case with chronic golfer’s elbow pain.
In fact, the majority of chronic elbow pain is due to a sprain of the annular ligament, although the ulnar collateral ligament, or tendons, as is the case with tennis and golfer’s elbow, may also be involved.
Prolotherapy is a specialized, regenerative injection technique that stimulates the body to repair and requires almost no down time. It is ideal for athletes who need to continue training for playing in upcoming competitions, and even the amateur athlete who doesn’t want to stop the a beloved sport.
In our own published research in the medical journal Practical Pain Management, our Caring Medical team found that:
- “Prolotherapy helps decrease pain and stiffness and improve the quality of life in patients with unresolved elbow pain.
- The treatment gave 64% percent of patients greater than 75% pain relief with 94% of them having 50% or more of their pain relieved.
- One hundred percent of the patients stated their pain and their life was better after prolotherapy.
- Notable improvements in other quality of life issues—including range of motion, depression, anxiety, sleep, exercise ability and medication usage—was also seen with prolotherapy.”
While the normal proliferant used in prolotherapy is dextrose-based, PRP prolotherapy (Platelet Rich Plasma as demonstrated in the video above) is gaining in popularity. In PRP prolotherapy, a concentrated amount of one’s own platelets which contain growth factors are injected into the injured tissue to promote and speed up the body’s natural healing process.5
If you have questions about elbow pain and inflammation, get help and information from our Caring Medical staff
3 Laratta J, Caldwell JM, Lombardi J, Levine W, Ahmad C. Evaluation of common elbow pathologies: a focus on physical examination. The Physician and Sportsmedicine. 2017 Apr 3;45(2):184-90. [Pubmed] [Google Scholar]
5. Abate M, Salini V, Schiavone C, Andia I. Clinical benefits and drawbacks of local corticosteroids injections in tendinopathies. Expert Opin Drug Saf. 2017 Mar;16(3):341-349. [Pubmed] [Google Scholar]
6 Hauser RA, Hauser MA, Hollan P, Hackett-Hemwall Dextrose Prolotherapy for Unresolved Elbow Pain. Practical Pain Management. October 2009;14-26.