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.
- Medial epicondylitis is often manifested in a professional or in a sports 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.
A move towards injection treatments in 2020
Here is a 2020 guideline (2), which 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.
- Initial management of medial epicondylitis should include rest from pain-causing activities. This would include a complete stop of activities, decreasing their volume, frequency, or intensity. The provider should recognize that this may not always be possible depending on the patient’s occupation. For example, a professional athlete or laborer may not be able to afford to take time off.
- Patients may respond to pain management including non-steroidal anti-inflammatory drugs and acetaminophen. Opioids are not indicated. Ice can be helpful especially after activity. Topical nitroglycerin patches have proven helpful in treating tendinopathies.
- Physical therapy is the primary management modality for medial epicondylitis.
- Strength exercises should focus on eccentric activity. Multiple modalities that may provide relief include dry needling, extracorporeal shock wave therapy, electrical stimulation, iontophoresis (electrical current is passed through skin soaked in tap water), phonophoresis (using ultrasound to help a topical skin gel penetrate deeply into the muscle), and ultrasonography (Ultrasound used as a nerve block application). Soft tissue and manipulation techniques appear to allow more vigorous strengthening and stretching, resulting in better and faster recovery from the symptoms of medial epicondylitis.
- Night splinting with a cock-up wrist splint may be helpful. A counterforce brace can unload the tendon, decreasing pain.
- Elbow taping with kinesiology taping may also be useful.
- Ultrasound or palpation-guided corticosteroid injections can be used.
- Platelet-rich plasma injections have been shown to reduce pain and improve function in refractory epicondylitis.
- Botox injections have been studied as an off-label treatment and have some literature support in refractory cases.
- Prolotherapy may also provide relief in refractory cases.
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:
- When patients have chronic elbow pain whether this pain comes from playing tennis or golf or work-related repetitive injury, and this injury does not heal or resolve in a few weeks and seems to ” never get better,” we have to suspect what is happening is that the tendons of the elbow are suffering from tendinosis or degeneration of that tendon. This is elbow pain and loss of function usually without any inflammation. (Tendinosis – pain without inflammation).
Treatments that do not help:
- Patients with chronic elbow pain, whether it is Tennis Elbow or Golfer’s Elbow will often try programs of ice, anti-inflammatory medications, KT Tape or Kinesio tape on it, physical therapy, rest, the whole gamut of conservative care options. This is when these people come to see us. When everything else has not worked or even helped and they are looking for another option to help their chronic elbow pain.
Injections beyond cortisone
- Prolotherapy or proliferation therapy is an injection technique that can work to regenerate the degenerated tendon. The injection of simple dextrose initiates a signaling response that recreates and mimics a natural healing response. The injections stimulate healing growth factors and repair platelets from the blood and immune response that makes healthy new tissue.
In-office ultrasound as compared to MRI for determining tendon tears in the elbow
- There are times when the degenerative tendon disease in the elbow has progressed to micro-tearing or more substantial tearing. In some cases, we may use an ultrasound machine instead of sending patients for MRIs to determine the extent of the tendon damage. If it is fraying or micro-tearing, then we can guide our treatments one way. If a more substantial tear is present, then we can guide our treatments another way. This is done in our office, and upon completion of the ultrasound examination, we can start treatment immediately with this new information.
A 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. 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 is 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).
- 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.
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 benefits, 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:
- “local glucocorticoid 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 have 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.”
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 clinic.
- 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 the ulnar is.
- So we treat the ulnar collateral ligament thoroughly and this is a much better treatment option for some patients than Tommy John surgery and as you can see it just takes a couple of 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 downtime. 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:
- “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 a range of motion, depression, anxiety, sleep, exercise ability, and medication usage—were 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.
If you have questions about elbow pain and inflammation, get help and information from our Caring Medical staff
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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]
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