Injections for Golfer’s Elbow – Medial epicondylitis

Ross Hauser, MD
Danielle R. Steilen-Matias, MMS, PA-C

Often a patient will come into our office with a history of elbow pain, mostly centered on the inner side of the elbow. The patient tells us they got this because they play golf or tennis, or they are a baseball pitcher. Many people also get this in their work as a laborer as they do physically demanding work, such as in a warehouse, construction, farming, or any job that requires an overhead or overarm motion. After a self-management plan of painkillers, anti-inflammatories, taping, straps, and bracing, their pain did not subside and became bad enough that the patient tells us that they had to seek medical care.

Usually, we are not the first medical office that they come to. Patients will tell us about the referral to an orthopedist and after a prescription for a stronger dose of anti-inflammatories does not help long-term, a cortisone injection is given. Most of our patients tell us that the first cortisone injection worked like a miracle, that they were cured. Until, however, the pain came back. Usually 3 to 4 months after the injection. The patient was now back on painkillers for fear of further cortisone injections causing tendon damage, and they began their search for alternatives and options to help them. Eventually, they show up in our office.

This is what we hear:

The construction worker:

I have been in construction all my life. I use to swing the big hammers, do a lot of demolition, lift a lot of heavy stuff. Now I have this chronic inflammation and burning in both elbows. To keep working I have been using compression sleeves and more NSAIDs than I should be taking. At night I have numbness and pain, I cannot find a comfortable sleeping position. I know lack of sleep is really bad for me and any hopes of healing. Cortisone is still working for me but I know that this is not long-term. My other doctor is now limiting the number of injections I can get.

My son the pitcher:

We have been all over the place and have had a lot of recommendations. The one thing that got to me is that these recommendations we were getting, none of the doctors seemed to have any confidence in. We did get a lot of recommendations to rest the arm and if we had patience, velocity would return. Obviously, time is of the essence, we do not want to miss any time on the disabled list if we do not have to but we certainly do not want to jeopardize causing damage that will lead to possibly a missed season. This is why we are exploring regenerative injections.

Initial misdiagnosis and delay of treatment

Medial epicondylitis, “Golfer’s elbow,” or sometimes referred to as “Pitcher’s elbow,” is a form of tendonitis, that is inflammation 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 at the bone and where the painful inflammation occurs.

By far the most common cause of medial epicondylitis 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.

There is no consensus on treatment. After a period of rest, stretching then strengthening exercises are recommended.

Here is the medical assessment of medial epicondylitis in the medical literature. It is a 2015 summation of the problem of diagnosis and treatment of this elbow pain:(1) Let’ see if there have been any new developments since.

A move towards injection treatments in 2020

Here is a 2020 guideline (2), it is published in the book StatPearls. While general recommendations remain the same, we will be examining the injection recommendations of cortisone, botox, Platelet-rich plasma, and Prolotherapy more closely.

Some of these treatments, especially Prolotherapy, are treatments that may not have been offered to you or that your doctor has even heard of. It will be explained below.


Danielle R. Steilen-Matias, MMS, PA-C gives a brief introduction to our treatment protocols for healing chronic elbow pain

Summary transcript and learning points:

Treatments that do not help:

Injections beyond cortisone

In-office ultrasound as compared to MRI for determining tendon tears in the elbow

Physical examination will benefit the patient with elbow problems more than a diagnosis based solely on MRI

One of the problems with this type of elbow pain is an over-reliance on what an MRI suggests and how that image is interpreted by your doctors.

In an article in The Physician and Sports Medicine, (3) 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. 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.”

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 (4) 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 epicondylitis 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).

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.

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. 

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 (5) write of these concerns in research from March 2017:

In this video Ross Hauser, MD and Prolotherapy clinician student demonstrates Prolotherapy medial elbow treatment

The treatment begins at 1:12 

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 their beloved sport.

In our own published research in the medical journal Practical Pain Management, (6) our Caring Medical team found that:

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.

If you have questions about elbow pain and inflammation, get help and information from our Caring Medical staff

1 Dumusc A, Zufferey P. Elbow tendinopathy Rev Med Suisse. 2015 Mar 11;11(465):591-5. [Google Scholar]
2 Kiel J, Kaiser K. Golfers Elbow. InStatPearls [Internet] 2019 Apr 16. StatPearls Publishing. [Google Scholar]
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]
4 Arrigoni P, Cucchi D, Menon A, Randelli P. It’s time to change perspective! New diagnostic tools for lateral elbow pain. Musculoskeletal surgery. 2017 Aug 2:1-5. [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. [Google Scholar]
6 Hauser RA, Hauser MA, Hollan P, Hackett-Hemwall Dextrose Prolotherapy for Unresolved Elbow Pain. Practical Pain Management. October 2009;14-26. [Google Scholar]

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