Golfer’s Elbow Medial epicondylitis

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 offices.

Initial misdiagnosis and delay of treatment

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 at the bone 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.

Doctors in France writing in the medical literature give a good summation of the problem of diagnosis and treatment of this elbow pain:(1)

  • 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.

In other research, this time from doctors at the University of California, San Diego, (2) suggested microtenotomy using a radiofrequency probe to treat chronic tendinosis of the elbow. This study focused on patients who failed conservative treatment for 6 months.

laser or radiofrequency microtenotomy for elbow epicondylitis surgery to cut the tendon was recommended in difficult cases.2
Elbow ultrasound

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

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

The treatment begins at 1:12 

  • Chronic elbow pain is a very prominent problem that we see in our clinics.
  • I’m Dr. Ross Hauser here I’m teaching a student how to inject the medial elbow area which is commonly called golfer’s elbow. It’s also known as ulnar collateral ligament injury which occurs in people who do overhead activities like tennis or baseball pitchers.
  • (1:47) You’ll  see here that I have the student put their index finger over the ulnar nerve, this is very key so the injection is done at the right place and not done into or around the ulnar  nerve, see how I’m showing the student the right angle of the needle to inject the medial epicondyle area as well as other areas around the ulna bone where the ulnar collateral ligament attaches so the students going to mainly be treating the attachment the medial epicondylitis attachment of the wrist and hand flexors these are the muscles that contract the fingers.
  • (2:43) The average number of treatment/visits is 3 – 6 treatments spread out over 4 -6 weeks per treatment.
  • The student is injecting the various attachments of the ulnar collateral ligament which is the main stabilizer of the elbow the insider medial elbow and she has left index finger where they ulnar is.
  • So we treat the ulnar collateral ligament thoroughly and this is a much better treatment option from some patients than Tommy John surgery and as you can see it just takes a couple minutes

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


PRP vs surgery

In this study, the researchers compared 2 methods of treatment, 15 patients were treated with a series of 2 leukocyte-rich PRP injections, and 18 patients were treated with surgery. This is what the researchers documented:

  • A statistically significant improvement was noted in both time to full ROM (42.3 days for PRP vs 96.1 days for surgery) and time to pain-free status (56.2 days for PRP vs 108.0 days for surgery).
  • Successful outcomes were observed in 80% of patients treated with PRP and 94% of those treated operatively.

CONCLUSION: In this case series, the use of PRP showed clinically similar outcomes to those of surgery in recalcitrant type 1 Medial epicondylitis. PRP can be considered as an alternative to surgery in the treatment of recurrent Medial epicondylitis, with an earlier time to full ROM and time to pain-free status compared with surgery.

https://www.ncbi.nlm.nih.gov/pubmed/32232070

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]
Tasto, MD JP et al. Radiofrequency Microtenotomy for Elbow Epicondylitis: Midterm Results. Am J Orthop. 2016 January;45(1):29-33 [Pubmed] [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. [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.

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