Golfer's elbow is called medial epicondylitis in clinical settings, and it is a form of tendonitis. The inflammatory condition is marked by pain in the tendons of your forearm muscles that get attached to the bony bump on the inside of your elbow. The pain tends to spread into the forearm and wrist in severe cases.

Golfer's elbow is similar to tennis elbow. The difference lies in the tendons involved. The tennis elbow consists of the forearm muscles attached to the outside or lateral of the elbow. In contrast, the golfer's elbow is the inflammation of the tendons attaching to the inside or medial of the elbow.

The underlying causative factor is the repeated use of wrists or fingers (like tennis or golf).

The anatomy of the golfer's elbow

The muscles of the forearm that pull the hand are called wrist flexors. These muscles lie on the palmer side of the forearm. Most wrist flexor muscles get attached as one central tendon, the common flexor tendon, on the medial epicondyle.

The wrist flexors contract while flexing the wrist, twisting your forearm down, or when you are trying to grip something with your hand. The forces that pull on the tendon and cause injury to build up, for example, during a golf swing.

Causes of golfer's elbow

The underlying causative factor of the golfer's elbow lies with damage to the muscles and tendons that control the movement of the wrist and fingers.

The leading causes include;

• Excessive stress or repeated movements, especially those involving forceful wrist and finger movements
• Improper lifting, throwing, or hitting an object
• Inadequate warm-up, poor technique, or poor conditioning of the muscles
• Improper technique while playing racket sport, especially the backhand stroke
• Excessive use of topspin technique
• Using a racket or other sports equipment that is too small or heavy
• Improper pitching technique in games like baseball, softball, football, archery, and javelin throwing
• Lifting weights with an improper technique, for example, curling the wrists during a biceps exercise

Repeated activities carried out for more than an hour a day on many days cause a golfer's elbow.

Smoking, being overweight and obese, advancing age increases the risk of developing a golfer's elbow.

Symptoms of golfer's elbow

The signs and symptoms of a golfer's elbow may appear suddenly or develop gradually. The condition presents itself as;

• Pain on the inner side of the elbow; the area may be tender to touch
• Pain that extends along the inner side of your forearm down to fingers
• Worsening of the condition with specific movements, for example, making a fist or clenching the fingers
• Stiffness of the elbow joint
• Weakness in the hands and wrists
• Numbness or tingling radiating into one or more fingers (usually the ring and little fingers are involved)

Diagnosis

History of the presenting complaints and a physical examination confirm the diagnosis.

An X-ray helps to rule out fracture or arthritis, some other causes of elbow pain. Very rarely, your doctor may suggest an MRI scan for your condition.

Treatment of golfer's elbow

The treatment follows the mandatory protocol for all sports injuries.

1. Immediately after the injury to first few days

1. RICER

Rest and take a complete break from any activity aggravating the situation.

The application of ice or cold compress helps if applied immediately after injury.

Elevating the arm by using a sling may be required in severe cases. It helps to immobilize the arm reduce swelling and pain of the inflammation.

If symptoms worsen or do not get better, time to see a consultant.

• Medications

Over-the-counter pain reliever helps to manage the pain of the golfer's elbow. Ibuprofen, naproxen sodium or acetaminophen can be taken.

Corticosteroid injections may not help to manage the condition over the long term.

Platelet-rich plasma injections into the inflamed area may speed up recovery.

• TENS

TENS does help manage the pain of a golfer's elbow. The electrical stimulation of TENS follows the same pathway as the pain pathway in the brain, thereby helping to cancel the pain. TENS is an effective alternative to pain medication.

For the golfer's elbow, place the electrode pads above and below the elbow on the inside of the joint. Do not place the electrodes on the bone.

• Surgery

Surgery for a golfer's elbow is very rarely required. Failure to respond to conservative treatment in six to 12 months may merit surgery. A newer surgical technique is called TENEX. The procedure is minimally invasive and involves the removal of scar tissue under ultrasound guidance.

• After few weeks following the injury

• Massage

Transverse friction massage works effectively for the golfer's elbow. The massage is carried out with the help of fingers and aimed at the tendons and muscles. Massage helps to increase the local temperature and enhance blood circulation. It speeds up the healing and recovery of the affected tendons.

The particular aspect of transverse friction massage is that it prevents cross-linkages of the collagen fibers and reduces scar formation. This helps in resolving the flexibility and range of motion of the elbow joint.

• Therapeutic ultrasound

Therapeutic ultrasound helps to warm the area, which stimulates blood supply. It slows the nerve condition that contributes to alleviating pain. Healing is enhanced with ultrasound therapy, and inflammation is reduced.

For the golfer's elbow, the head of the ultrasound machine is continuously moved over the area to avoid any vibration injury. A large head uses 3 MHz to treat a golfer's elbow. The therapy can be applied three times every day, with each session lasting 3-5 minutes.

• Active rehabilitation

After the initial injury heals and there are no signs of inflammation, active rehabilitative exercises should be adopted to gradually increase the strength of the muscles, heal the tendons and improve joint flexibility.

Progressively increasing the load on the tendons with specific strength training exercises, called eccentric, are effective.

Eccentric exercises relax the muscles. The aim is to strengthen the flexors of the arm by working against gravity. Some of these include;

Eccentric strengthening exercise

• Sit down on a chair and hold a weight in the affected hand.
• Do not use heavyweights. It should be 30% of the weight you can easily hold.
• With your arm stretched and elbow bent, rest your affected arm on the respective thigh.
• Slowly lower the hand holding the weight.
• Then bring the hand back to its starting position. If you feel pain, support your affected arm with the other hand.
• Repeat 10 to 15 times.
• Repeat at least two more sets.

Stretching exercise for golfer's elbow

The aim is to stretch the wrist flexor muscles in the forearm. These exercises improve the mobility (range of movement) of the arm and wrist.

• Extend the affected arm out in front of you. Your palm should face upwards.
• Relax your wrist on the affected side so that your hand comes in a fallback position.
• Using your other hand, pull and stretch the affected hand back towards your body.
• Hold the stretch for at least 30 to 45 seconds.
• Repeat three times while taking breaks in between the sets.

Isometric wrist strengthening (extension)

• Make sure to keep your body still throughout this exercise.
• Sit on a chair and place your affected forearm on a table with your palm facing down on the table.
• Place the healthy hand on the back of your affected hand. It will provide resistance to the movement.
• Make a fist with the affected hand.
• Move your affected hand up.
• Continue making a move for at least 10 seconds and gradually increase the resistance.
• Release and rest.
• Do at least 15 reps.

Isometric wrist strengthening by flexing the hand in the opposite direction of the exercise mentioned above is the other facet of this exercise.

Prevention of golfer's elbow

Since repeated movements cause a golfer's elbow, it is imperative to take preventive measures to save yourself from this painful condition.

• Start with exercising forearm muscles by doing resistance workouts. Initially, use light weights. Squeeze a softball to work the muscles that control fingers.
• Adopt proper warm-up techniques before starting exercise.
• Stretching after a workout is vital to strengthen the muscles.
• Maintain proper form during exercise or playing a sport.
• Avoid undue load on your arms.
• Always select the right sports equipment. Use lightweight rackets to avoid injuring your forearm muscles.
• Take appropriate rest at the first signs of injury.