- 1 Early history of medial epicondylitis
- 2 Who is at risk of developing medial epicondylitis?
- 3 How does the condition present?
- 3.1 Doctor’s Examination
- 3.2 Other disorders that could be confused with golfer’s elbow
- 4 Investigations to establish the diagnosis of medial epicondylitis
- 5 How golfer’s elbow is treated?
- 5.1 Physical therapy and rehabilitation
- 5.1.1 Wrist flexor stretch:
- 5.1.2 Wrist pronator stretch:
- 5.1.3 Wrist flexion strengthening exercise:
- 5.1.4 Pronation/supination strengthening exercise:
- 5.1.5 Ball squeezes strengthening exercise:
- 5.1.6 Phonophoresis
- 5.1.7 Iontophoresis
- 5.1.8 The role nonsteroidal anti-inflammatory drugs ‘NSAIDs’
- 5.1.9 The role of rest, ice, compression, and elevation ‘RICE’ method
- 5.1.10 The role of counterforce bracing and cock-up wrist splints
- 5.1.11 The role of corticosteroid injection
- 5.1.12 Other treatment modalities
- 5.2 The course of treatment
- 5.3 Surgical intervention for golfer’s elbow
- 5.4 A discussion of the procedure’s techniques
- 5.1 Physical therapy and rehabilitation
Early history of medial epicondylitis
Medial epicondylitis of the elbow, commonly referred to as ‘golfer’s elbow’, is a disorder develops due to pathologic changes in the forearm flexor and pronator muscles’ origin at the medial epicondyle. The medial epicondyle is the bony eminence at the inner side of the elbow joint. It was early described by Henry Morris in the 18th century as ‘lawn-tennis elbow’, epicondylitis has since been studied and written on with more attention. Although lateral epicondylitis, often referred to as ‘tennis elbow’, has received the majority of this attention, there exists a paucity of literature regarding golfer’s elbow. This is, most probably, due to its infrequent incidence of only 10% to 20% of all epicondylitis diagnoses. Examination of archaeological human bones by trained observers has shown that epicondylitis existed in the early history of humans, and it was mainly determined by bony pits and signs of healing process over the muscles attachment sites over both medial and lateral epicondyles. This is because of the repetitive forceful tasks and heavy labor the early humans used to do. As it is a common overuse and sports injury, medial epicondylitis has received much more medical and research attention in the 19th century.
Various names for the condition
Medial epicondylitis or golfer’s elbow, which is mainly characterized by pain from the elbow to the wrist on the inside ‘medial side’ of the elbow, is also known as baseball elbow, suitcase elbow, or forehand tennis elbow. In other medical text it is referred to as climber’s elbow. Medial epicondylitis was originally thought to be an inflammatory process, as the name suggests. Early descriptions postulated an inflammatory process involving the radial humeral bursa, periosteum, and annular ligament. However, these theories have recently been discounted by further histologic analysis. A number of studies revealed that the normal collagen architecture is disrupted by a fibroblastic and immature vascular response, an incomplete reparative process. Although in its earliest stages, medial epicondylitis may display inflammatory characteristics, the later stages demonstrate evidence of micro tearing, characterized by tendon degeneration, with or without calcification. These structural alterations are known as ‘angiofibroblastic hyperplasia’. After all, the usage of exact terminology in the description of the condition is essential for understanding its nature and establishing goals of therapeutic interventions.
Anatomy of the medial epicondyle
The medial epicondyle is a bony prominence located at the inside ‘medial’ lower end of the upper arm bone ‘humerus’. In contrary to the lateral epicondyle, the medial epicondyle is larger and slightly angulated posteriorly. The medial epicondyle gives attachment to a number of structures around the elbow joint, as the following:
The ulnar collateral ligament ‘UCL’:
Also known as the internal lateral ligament. The ligament is a thick triangular band uniting the distal aspect of the humerus to the proximal aspect of the ulna. The ligament’s main function is to stabilize the elbow joint at its medial side.
The pronator teres muscle:
The muscle is commonly involved in the development of medial epicondylitis, and it has two heads. The humeral head inserts in the supracondylar ridge just above the medial epicondyle, to form the common flexor tendon. The ulnar head is thin and arises from a small bony process known as the coronoid process of the ulna. Distally, the muscle passes obliquely across the forearm, and ends in a flat tendon, which is inserted into a rough impression at the middle of the radius. When contracts, the pronator teres pronates the forearm, which means to turn the palm to be facing posteriorly, when the elbow is extended. If the forearm is flexed to a right angle the pronator teres turns the palm to be facing the floor.
The common flexor tendon:
It is thought that the most common site of pathology in medial epicondylitis is the interface between the pronator teres and the flexor carpi radialis origins at the common flexor tendon. The common flexor tendon is a tendon attached to the medial epicondyle, and acts as the upper attachment point for the forearm flexor muscles.
The flexor muscles of the forearm:
By the common flexor tendon, several muscles which act mainly to flex the forearm and the wrist are attached the medial epicondyle. These include the flexor carpi radialis, the flexor carpi ulnaris, the flexor digitorum superficialis, and the palmaris longus. On the back of the medial epicondyle runs the ulnar nerve in a groove. Thus, on striking the medial epicondyle, a tingling sensation is produced in the ulnar nerve.
Precipitated by repetitive forced wrist extension and forearm supination, during activities involving wrist flexion and forearm pronation, the rate of stretching exceeds the tolerance of the common flexor tendon and the pathological degeneration cascade starts to appear at the origin of pronator teres and flexor carpi ulnaris muscles.
How frequent is it to get golfer’s elbow?
Although it is less common than lateral epicondylitis ‘tennis elbow’, medial epicondylitis is the most common cause of medial elbow pain. Despite the fact that the epidemiology of medial epicondylitis has rarely been studied, among a case series in a hospital population, the incidence of the condition has been estimated to be one person per every 100000 per year, approximately nine times less common than lateral epicondylitis. In one population survey, it has been shown that the prevalence among women was about 0.6% compared to 1.1% among men. Currently, the proportion of medial epicondylitis occurrence among golf players is unclear.
Who is at risk of developing medial epicondylitis?
Many factors could contribute to the occurrence of medial epicondylitis. These could be classified into individual-related and occupational physical factors. Studies have identified several factors that may place an individual at greater risk for the development of medial epicondylitis. Older age, obesity, smoking, and diabetes mellitus are the most prominent individual risk factors. The manner in which these elements place a person at greater risk is unclear. After all, any medical illness, which would affect the healing process in the common flexor tendon, could simply lead to a degenerative state and participate as a risk factor for the condition’s incidence. In athletes, the condition is typically associated with overhead throwing, golf, or tennis; however, it has been found to be associated with other sports, including football, weightlifting, and bowling. Yet many other physical factors can stress the tendon and increase the risk to develop golfer’s elbow. Manual handling of loads, such as manually lifting, carrying, pushing, or pulling heavy items, could produce pain over the medial epicondyle. Manual tasks demanding high handgrip forces and repetitive movements of the hands or wrists would also cause medial epicondylitis on the long run. These tasks include squeezing, twisting, packing and sorting out items. Individuals with keying job, such as typewriting, cash register work, and workers who use vibrating tools, are at a higher risk of having symptoms of medial epicondylitis. One of the major risk factors of golfer’s elbow is the improper technique tennis players may use with poor serves and forehand strokes. Finally, any repetitive valgus movements that excessively stretches the common flexor tendon could increase the risk of developing golfer’s elbow.
How does the condition present?
Athletes complain mainly of insidious onset of pain over medial epicondyle with radiation into the proximal forearm. The pain is generally exaggerated with wrist and forearm motion, hand gripping, and during overhead throwing acceleration phase. In more chronic cases, patients may also complain of grip weakness. A thorough history is critical to determine the likelihood of medial epicondylitis. The history may include acute traumatic blow to elbow causing avulsion of the common flexor tendon, or repetitive valgus stress and elbow use. The condition may be associated with numbness or tingling in ulnar digits due to involvement of the adjacent ulnar nerve.
By palpation, pain is elicited 5 to 10 mm distal and anterior to the medial epicondyle. Your doctor may notice soft tissue swelling and warmth over the inside of your elbow, if inflammation presents. Initially full range of motion of the afflicted extremity can be maintained, but over time the range of motion may become limited as flexion contracture may develop, which is commonly noted in throwing athletes. Resisted wrist flexion, forearm pronation, or forceful grip may exacerbate elbow pain, and these resisted movements may be weakened when compared to the contralateral side. Pain may also be produced when the clinician tries to passively supinate and extend the wrist joint. This is because of the stretch exerted on the common flexor tendon. A study by Vinod et al found that pronation weakness at right angle is considered to be a reliable physical examination finding, for determining significant pathologic changes in patients with medial epicondylitis.
By examination, the peripheral neurovascular state should be typically intact, except for other condition associations. Ulnar neuropathy is commonly associated with medial epicondylitis. Tinel’s sign, which is determined by tapping over the nerve, and two-point discrimination should be checked to rule out ulnar neuritis. The ulnar nerve provides sensation to the fifth digit, half of the fourth digit, and the corresponding aspect of the palm. The elbow flexion test for ulnar neuritis is performed by positioning the elbow in full flexion, the forearm in pronation, and the wrist in maximum extension for approximately 30 to 60 seconds. If the patient experiences medial elbow pain, as well as tingling in the ring and little fingers, the test result is positive. Hypertrophy of the medial head of the triceps may cause compression to the nerve against the medial intermuscular septum, and signs of ulnar nerve neuropathy are consequently produced. Valgus instability, due to injury of the medial ulnar collateral ligament in overhead athlete, should be carefully examined using tests such as moving valgus stress test.
Other disorders that could be confused with golfer’s elbow
Since approximately 84% of occupational patients may have concomitant work-related disorders, individuals suspected of having golfer’s elbow should be carefully examined for other pathologies in the ipsilateral limb. The following diagnoses, which may be associated with or mimic medial epicondylitis, should be clinically excluded:
In tennis elbow the pain is over the lateral side of the elbow and may be exaggerated by resisted wrist extension rather than resisted flexion in golfer’s elbow.
Rotator cuff tendinitis:
A condition that could affect overhead athletes due to frequent extension of the arm. Pain in the front of your shoulder and side of your arm, which is triggered by raising the arm, is the main presenting symptom.
Ulnar collateral ligament ‘UCL’ injury:
The ligament is of critical importance for valgus stability of the elbow. It is a common injury among athletes of throwing sports. When the ligament is injured, the athlete experiences pain over the medial side of the elbow similar to that of golfer’s elbow. However the tenderness in UCL injury is localized approximately 2cm distal to the medial epicondyle, and it is not usually aggravated by resisting forearm pronation.
Elbow and forearm overuse injuries:
Overuse injuries of the elbow and forearm are common disorders in athletes subjected to repetitive elbow and wrist flexion-extension motion. Anterior capsule strain, pronator syndrome, radial tunnel syndrome, biceps tendinosis, and triceps tendinosis are common examples of elbow and forearm overuse injuries that could present similarly with slight history and examination differences. A thorough history here and careful examination are inevitable to differentiate these conditions that could mimic one another.
Little league elbow syndrome:
An overstress injury to the medial elbow that develops as a result of frank throwing motions in children. Repetitive stress to the growth plate in the medial epicondyle, during the acceleration phase of throwing, results in aching sharp pain, and swelling on the medial side of the elbow. Plain radiographs may detect calcified loose bodies, and growth plate irregularities and widening.
Dysfunction of a nerve root of the cervical spine, secondary to degenerative changes, may cause pain over the elbow and forearm. However, the pain of cervical radiculopathy usually starts at the neck and travels down the arm, and certain head movement may increase its intensity. Patients with cervical radiculopathy of the C6 and C7 roots may be at higher risk of developing medial epicondylitis due to forearm muscle imbalance.
In addition to a thorough patient history and clinical examination, investigations should be applied to support or verify a diagnosis of medial epicondylitis.
Investigations to establish the diagnosis of medial epicondylitis
Laboratory studies are of minimal role, but can be helpful if patients are suspected of rheumatoid disorders.
Although most plain radiographs will demonstrate normal findings, up to 25% may show evidence of calcification adjacent to the medial epicondyle in the common flexor tendon or the ulnar collateral ligament. Therefore, radiography is rarely needed in the initial workup of this condition. However, if there is a history of a traumatic injury, and fracture is suspected, radiographs should be obtained. Plain radiographs can identify medial osteophytes ‘spurs’ or degenerative changes in throwing athletes. Furthermore, stress radiography in some centers is obtained for assessing valgus instability. In little league elbow, plain radiographs is necessary as the results are important to guide the patient’s treatment modalities. In contrary, ultrasonography is contraindicated in young patients with open growth plates.
Ultrasonography is a cost-effective modality for visualizing pathologic changes in the common flexor tendon. Traumatic tears to the flexor pronator origin at the medial epicondyle can be determined by ultrasonography. In one study, it was shown that a sonogram performed by a radiologist had sensitivity, specificity, and predictive values of 90% for diagnosis of medial epicondylitis. In ultrasonography, hypo-echogenic areas, where the echoes are weaker or fewer, indicate focal degenerations. One advantage of this modality is it allows dynamic examination, which could improve specificity and sensitivity. Although the ultrasonography has a high diagnostic value, the modality, to a great extent, is dependent on the operator and may be less accurate without well-trained sonographers.
Computed tomography ‘CT’ scanning is useful for evaluating stress fractures extended to involve the articular surface of the elbow joint.
Magnetic resonance imaging ‘MRI’ remains the gold standard for radiologic diagnosis of medial epicondylitis. . Pathologic changes in the tendon are easily detected by non-contrast MRI. Intermediate to high signal intensity at the common flexor tendon is highly indicative of medial epicondylitis. MRI can also detect other concomitant medial elbow pathologies, such as ulnar collateral ligament injury, and other elbow and forearm injuries. Moreover, MRI is useful to detect unclear sources of medial elbow pain, and to rule out rupture of the flexor pronator origin in golfer’s elbow patients. Generally, MRI is typically used when concomitant pathology is suspected, or if the clinical picture is unclear.
Electromyogram ‘EMG’ and nerve conduction studies are indicated to evaluate for ulnar nerve compression, if neurologic alterations is evident on history and physical examination.
How golfer’s elbow is treated?
Various nonsurgical and surgical treatment options are there to be used for management of golfer’s elbow. The goals, however, remain to relieve the acute symptoms, rehabilitate the injured tendon, and to prevent recurrence. As with many overuse injuries, conservative modalities are the initial and the mainstay of treatment. Treatment course usually starts with the acute phase to the recovery phase, and lastly the maintenance phase where the patient should be independent.
Physical therapy and rehabilitation
In athletes, the main goal of treatment is to regain full range of motion of the elbow joint. Randomized controlled trials aimed to assess the evidence for effectiveness of physical exercise therapy and mobilization for medial epicondylitis. Different therapeutic modalities, such as stretching, and strengthening exercises were evaluated. Short-term effectiveness was evidenced in favor of stretching and strengthening exercises in comparison to ultrasound and massage. Manipulation techniques of the cervical spine, elbow, and wrist may produce short-term analgesic effect which may allow more vigorous stretching and strengthening exercises. As a result, faster and better recovery process of the affected tendon is achievable. Another study was conducted to assess the outcome after adding eccentric ‘stretching’ wrist flexor exercise to the standard treatment regimens, for patients suffering from chronic medial epicondylitis. Interestingly, the symptoms were markedly improved after the addition of an eccentric wrist flexor exercise to the standard physical therapy.
Several techniques for stretching and strengthening exercises can be performed by the patient.
Wrist flexor stretch:
Keep your elbow straight and gently extend the wrist. Hold the wrist extended for 20 seconds, and repeat 3 times.
Wrist pronator stretch:
With your elbow bent, hold a wooden hummer rod, and use it to rotate the wrist so the palm is facing the ceiling. Hold in this position for 20 seconds, and repeat 3 times.
Wrist flexion strengthening exercise:
Place one end of a rubber resistance band under your foot and the other in your hand. With the palm facing the ceiling, flex your wrist upward, and repeat 10-30 times.
Pronation/supination strengthening exercise:
Place one end of a rubber resistance band under your foot and the other end in your hand. Rotate the wrist joint so that your palm faces both the floor and the ceiling. Repeat the movement 10-30 times.
Ball squeezes strengthening exercise:
Use a tennis or racquetball to squeeze in your hand 20-30 times.
Although few studies demonstrated the long-term benefits of their use, modalities such as electrical stimulation, phonophoresis, iontophoresis, and ultrasonography could be used to obtain short-term symptomatic relief.
Phonophoresis is the use of ultrasound to enhance the absorption of topically applied drugs through the skin. One study aimed to determine whether the pain after adding phonophoresis ‘PH’ differs from the pain after the use of ultrasound ‘US’ alone. Forty-nine subjects with soft tissue injuries, including medial epicondylitis, were assigned to PH or US treatment groups. In the PH group, a gel containing 0.05% fluocinonide ‘potent anti-inflammatory agent’ was used. At the end of 3 weeks of treatment, both groups showed a significant decrease in pain level and an increase in pressure tolerance. However, the addition of PH with fluocinonide did not augment the benefits of US used alone.
Iontophoresis, also known as ionization, is a safe medical procedure that involves sending mild electrical currents through water and to the skin. The procedure can be used to deliver anti-inflammatory medications directly into the skin. A comparison between the effects of phonophoresis and iontophoresis of naproxen ’a nonsteroidal anti-inflammatory drug’ in the treatment of epicondylitis was made, using a randomized controlled trial. The results suggested that iontophoresis and phonophoresis of naproxen are equally effective methods at short-term follow up. Preadolescent are often not compliant to physical therapy; therefore, its use should be considered carefully with this group of patients.
The role nonsteroidal anti-inflammatory drugs ‘NSAIDs’
The role of topical diclofenac for lateral epicondylitis, in which the pathophysiology is quite similar to that of medial epicondylitis, was examined in a randomized, double blind study. Topical 2% diclofenac appeared to provide short-term relief in elbow pain associated with chronic lateral epicondylitis. Although gastrointestinal upset commonly limits the use of oral nonsteroidal anti-inflammatory drugs, transdermal administration of NSAIDs could avoid these side effects. While, some physicians believe that the anti-inflammatory effects of NSAIDs are beneficial for decreasing swelling, thereby decreasing the time required for an individual’s recovery, others argue that the use of NSAIDs during the acute injury phase may augment the swelling by increasing the potential for bleeding via platelet inhibition. After all, the use of nonsteroidal anti-inflammatory drugs remains controversial. However, sometimes in athletes, acetaminophen may be required to control the pain.
The role of rest, ice, compression, and elevation ‘RICE’ method
RICE method is considered the mainstay for treating soft-tissue injuries. Athletes should decrease the amount, frequency, or intensity of activity that aggravates the condition. Ice is the main and first-line anti-inflammatory treatment for medial epicondylitis. However, icing should be started after the completion of stretching and strengthening exercises. Over-icing, where the ice is left on too long, could lead to temporary ulnar nerve injury. The ideal time for placing an ice pack is 15-20 minutes. Ice bath can be made using a sink filled with ice and water, and the athlete soaks his elbow for 10-15 minutes. Icing could be in the form of an ice pack or an ice water bath. To make an ice pack, crushed ice is put in a plastic bag which could be wrapped in a towel to increase the contact area. After that, the ice pack could be mold to fit the elbow’s shape. Frozen corn kernels wrapped in a towel is a good alternative. Compression and elevation is beneficial for increasing the speed of recovery, because these methods decrease the edema and swelling.
The role of counterforce bracing and cock-up wrist splints
These are used as adjunctive therapies for treating medial epicondylitis. During activities, athletes can use a counterforce brace. Theoretically, the brace decreases the contraction forces, exerted by the flexor-pronator muscles, on the medial epicondyle. Cock-up wrist splints are designed to keep the forearm in neutral position, so that these types of splints are useful for athletes who awaken with elbow pain. Elbow taping by two strips is sometimes used to support the joint by restricting its flexion movement. When used correctly, elbow taping can decrease pain during activity and aid the healing process. A preliminary study was done to determine the initial effects of elbow taping on pain-free grip strength and pressure pain threshold, in patients with lateral epicondylitis. Ameliorating effect of taping technique was evident, and this suggests that it can be considered as an adjunctive modality in the management medial epicondylitis.
The role of corticosteroid injection
A prospective study of sixty elbows was done to determine the efficacy of an injection of steroids for golfer’s elbow. The short-term and long-term effects of the local injection of methylprednisolone were analyzed. Fifty-eight patients were assigned to experimental group, treated with methylprednisolone injection, and control group, received saline solution injection. Six weeks after the injection, the experimental group showed significant decrease in pain compared to the control group. However, the two groups did not differ regarding to pain at three months and at one year follow up. In conclusion, the local injection of steroids provides only short-term benefits, but no significant difference is noticed at the long-term follow up. In cases with recalcitrant medial epicondylitis, corticosteroid injection is usually considered. The technique of corticosteroid injection for medial epicondylitis is relatively simple. Using a sterile technique, the area of maximal tenderness is injected with a small amount of the drug. Depigmentation after local corticosteroid injection is a potential side effect in patients with more darkly pigmented skin.
Other treatment modalities
Autologous blood or platelet rich plasma ‘PRP’ injection into the site of tenderness are considered as an effective alternative treatment modalities. Autologous blood injection ‘ABI’ is a safe medical procedure which involves injecting the patient’s blood into an injured part of his body. The effect of ultrasound guided autologous blood injection, as a treatment for medial epicondylitis, was assessed in one study. Patients were examined at 4 weeks and at 10 months, after the autologous blood has been injected. The results suggested that autologous blood injection under ultrasound guidance is an effective therapy for refractory medial epicondylitis. Significant reduction in pain score 10 months post-procedure was evident. The effects of platelet-rich plasma and autologous blood for the treatment of chronic lateral were compared in a randomized controlled trial. PRP treatment appeared to be effective and superior to autologous blood in terms of pain reduction at the short-term. Adjusting concentration, number, and time of platelet-rich plasma injections might increase the effectiveness and reduce the cost of this treatment modality. Theoretically, PRP and ABI is thought to stimulate an acute inflammatory reaction and increase the concentration of various growth factors, such as transforming growth factor-beta, basic fibroblast growth factor, platelet-derived growth factor, epidermal growth factor, vascular endothelial growth factor, and connective-tissue growth factor, at the site of injured tendon. This leads to reactivation of the cascade of the healing process.
Botulinum toxin is a neurotoxic protein produced by a gram-positive anaerobic bacterium, known as clostridium botulinum. Injection with botulinum toxin is another possible alternative treatment option. However, at this time, the role of botulinum toxin for treatment of medial remains controversial.
Extracorporeal shockwave therapy ‘ESWT’ is used to treat an increasing number of musculoskeletal conditions. The advantage of extracorporeal shockwave therapy is that the method bears no significant adverse effects, and it was reported, by a double blinded study, as an excellent modality for treating lateral epicondylitis. Extracorporeal shockwave therapy promotes healing and reduces symptoms in various tendon conditions, at the short-term follow up. This modality is often recommended at the initiation of a nonsurgical program; however, if pain relief is not obtained soon after initiation, it should be discontinued.
Nitroglycerin transdermal patches, as modulators of nitric oxide, stimulate collagen production by fibroblasts. Most studies investigated the efficacy of nitroglycerin patches as a treatment for lateral epicondylitis, and significant improvement was noted in the nitroglycerin patches group compared with the placebo group.
The course of treatment
The course of non-surgical treatment can be divided into three phases. At the beginning, in the first phase, the athlete should immediately avoid offending activities, but complete immobilization or inactivity is not recommended in order to avoid muscle atrophy, which could hinder rehabilitation efforts. Rest, ice, compression, and elevation ‘RICE’ method is recommended at this time. Oral nonsteroidal anti-inflammatory medication may be added for a ten-day course, if the patient has no medical contraindications. If there is no response to these measures, splinting and counterforce bracing are appropriate, with local corticosteroid injection around the painful tendon insertion. In the second phase, as soon as symptoms are improved by the treatment in Phase 1, maintaining full, painless, wrist and elbow range of motion is the goal. Stretching and strengthening exercises should be initiated. The achievement of muscle strength greater than before injury is the ultimate goal, because before injury the muscle strength was proved to be vulnerable to tension overload. In this phase, sports or occupational simulation is planned. If this simulation is completed satisfactorily, sport or occupation can be reinitiated gradually. Finally, in phase 3, when the athlete returns to play, it is critical to identify any inadequacies in the sport’s equipment or techniques that may contribute to the recurrence of symptoms. Equipment properly sized to the athlete is particularly important in racquet sports, to prevent subsequent bouts of the condition. Some measuring techniques are used to accurately calculate the grip size from the proximal palm crease to the tip of the ring finger, along the radial border. Golf clubs of proper weight, length, and grip are essential to reduce the traction forces generated over the elbow, and subsequently help preventing the development of medial epicondylitis. Proper playing techniques should also be examined to prevent recurrence or development of golfer’s elbow. Laborers whose occupations adds risk of medial epicondyle injuries should evaluate their workplace and apply any necessary changes, to minimize repetitive motions.
Surgical intervention for golfer’s elbow
Surgical intervention is usually reserved for patients whose condition does not respond to conservative treatment for a period of 6 to 12 months. Surgeons has described various techniques; however, most of which consist of release of common flexor tendon and excision of the pathologic tissue. Regarding the outcome, good results have been reported in more than 80% of patients. For athletes, return to sporting activity is usually within 4 to 6 months after the surgery. A new technique has been recently described, in which the main principle is fascial elevation and tendon origin resection ‘FETOR’. The technique’s efficacy for the treatment of chronic medial epicondylitis was examined in one study. A total of 22 elbows in 20 patients suffered from recalcitrant medial epicondylitis were included. There was a great benefit from the surgical intervention in terms of the reduction of pain at rest and during work, the increase pain-free grip strength, and the function in general, at follow-up period ranged from 16 to 77 months. The study concluded that the FETOR technique is an effective and safe method of treatment for chronic refractory medial epicondylitis. Athlete with definitive tendon disruption, which is evident on MRI, should be elected for surgical repair of the tendon. This repair allows return to sport at nearly the same performance levels as before injury, earlier than nonsurgical treatment.
A discussion of the procedure’s techniques
Due to the risk of iatrogenic injury placed on the medial collateral ligament and the ulnar nerve during elbow arthroscopy, surgical management of medial epicondylitis is currently performed using an open procedure. An incision is made at the medial epicondyle. Great care is taken to avoid iatrogenic injury to the medial antebrachial cutaneous nerve while dissecting the subcutaneous tissue. Pathology of the pronator teres muscle is common, and further exposure of diseased musculotendinous tissue is mandatory. The common flexor tendon is exposed and examined for focal lesions, which are debrided, and with side-to-side tendon repair is performed. More extensive debridement may be required for lesions with severe disease, and the common flexor tendon is reattachment to the medial epicondyle. It is inevitable to micro-fracture the medial epicondyle prior to the reattachment in order to provide a vascular bed for the tendon to reinsert. Using this technique, Vangsness and Jobe reported excellent results in 34 of 35 patients with medial epicondylitis, at 6-year follow-up. Using a mini-open muscle resection technique in 10 patients, Cho et al described a modified method. A 1.5-cm incision is made at the medial epicondyle, and the common flexor tendon pathology is exposed, which was grossly excised. Micro-fracture is made to the medial epicondyle, and the overlying fascia is simply closed over the tendon to create an enclosed hematoma which promotes healing. Surprisingly, the debrided tendon is not repaired nor is it removed and reattached to the epicondyle. Although all 10 patients returned to their occupations within 3 months and no poor results were reported, the technique may limit the exposure of the ulnar nerve, which may be symptomatic and require decompression.
Finally, golfer’s elbow is a common sporting injury, which could affect athletes and laborers as well, and could be easily avoided via following proper exercising techniques and avoidance of improper movements during sporting activities. If you suffer from symptoms that suggests golfer’s elbow, do not be anxious, because various treatment modalities are there for you to return to your normal life.