Do you have a niggling pain on the inside of your elbow? Are you having difficulty picking up your coffee mug or swinging your golf club due to this discomfort? You may be struggling with golfer’s elbow.

Golfers elbow is an injury to one or more of the flexor tendons that attaches to the inside of your elbow. It is caused by repetitive overload that results in a constant irritation of these tendons. Even though it is commonly referred to as golfer’s elbow it actually more often than not effects people that do not play any sport at all. It tends to affect woman more than men roughly between the ages of 45-65. The pain tends to be localised around the inside of the elbow but it can radiate up and down the arm and sometimes one can feel numbness and tingling in the fingers.

You may have heard it being referred to as tendonitis, tendosis, medial epicondylitis or epicondylalgia but these are all describing the same condition golfer’s elbow. On a side note the preferred medical name for golfers’ elbow is actually medial elbow tendinopathy.

The flexor group of our wrist is composed of a number of muscles namely: pronator teres, flexor carpi radialis, palmaris longus, flexor digitorum superficialis, and flexor carpi ulnaris. These muscles appear with this order moving from the thumb side (radial) to the pinky side (ulnar) of the forearm. A commonality that they all share is that they all originate from the medial epicondyle of the humerus which is the round bump on the inside of your arm around your elbow and then insert at various sites on the distal forearm and hand. When one has medial epicondyle tendinopathy or golfer’s elbow as it is commonly known it means that you have damage to the tendons of the muscle and most frequently to the musculotendinous junction of the flexor carpi radialis and pronator teres muscles.

As we can see there are quite a few muscles that make up the forearm flexor group. There are some slight variations in their functions but collectively it boils down to a few forearm, wrist and finger movements.These movements consist of turning your forearm so that your palm faces downwards and is mainly done by the pronator teres muscle. This movement is common when opening or closing a door or using a screwdriver for example.

When all of these muscles work together as a group they will bend your wrist towards you. This is a common movement when you are writing or typing. There can be some variations to this such as bending your hand towards you away from like when you wave your hand. These movements are driven by the flexor carpi radialis muscle which will bend your hand away and the flexor carpi ulnaris muscle which will bend your hand towards you. Some of the forearm muscles even assist in bending your elbow.

Finally the movement of your fingers is done by the flexor digitorum superficialis and profundus muscles. These are important for gripping movements such as holding a hammer or a pen or a cup.

For the last few months you have been prepping for a golf tournament at your local club. You have had this little niggle on the inside of your elbow that you have been feeling every time you go to the driving range these last few weeks. So you just have been using some pain killers and ignoring it. As the day of the tournament approaches you feel like you just haven’t been getting enough repetitions in at the driving range so you decide to up the ante on the number of days you go to the driving range as well as the number of balls you hit. A few days in you start to realise that this elbow pain is getting worse and worse and you aren’t just feeling it at the driving range anymore as everyday activities are also starting to cause you a tremendous amount of pain. Eventually you end up missing the golf day because it’s just too painful to even try and grip a club let alone swing it.

What’s happened is that the repetitive golf swings coupled with the sudden increase of training frequency has overloaded the muscles and tendons of your wrist and finger flexors. This repeated stress eventually starts to tear and cause damage to your tendon leading to degeneration of the tendon. This means that the fibers have become disorganised and along with various other cellular changes causes the collagen fibers within the tendon to lose their strength making them more fragile and susceptible to injury. Your body responds to this by creating scar tissue which causes the tendon to thicken. If left unchecked this will cause your tendon to lose its strength, become less flexible and decrease its resistance to tearing, till it eventually reaches a point of complete disrepair.

Even though it is referred to as golfer’s elbow the majority of people that develop it don’t even play sport as it is caused by repetitive bend, twisting and gripping activities.

Overuse: this happens when you increase your training or work load too quickly such as sudden increase in the number of practice shots and the driving range or having to use a screwdriver more often due to increased work demands
Overload: occurs when a single event exceeds the capacity of your muscles or tendons to withstand the load such as suddenly doing a 100 practice swings in one go or suddenly having to use your screwdriver all day because your drill broke.
Weakness: when the muscle or tendon makes you more susceptible to overload as it is easier for exercise or activity to surpass the limits of the load that these structures can withstand.
Improper technique: as with any sport having incorrect form with your golf swing can unintentionally put more strain on the muscles and tendons in your forearm.
Poor warm-up: warm ups are important as they prepare our muscles, tendons and ligaments for the activities we are going to perform. This is vital for activities that have the potential to place a lot of load on these structures.

The current school of thought is that tendinopathies occur across a continuum that has the three phases: reactive tendinopathy, tendon disrepair and, degenerative tendinopathy. A tendon can move up and down this continuum depending on how load is managed, especially within the early phases of a tendinopathy.

Reactive tendinopathy (Stage one)

This is the first stage within the tendinopathy continuum which results from an overload of compressive or tensile forces on the tendon. At this stage the tendon’s collagen fibers still retain their strength but there are short term adaptations that occur such as elongation of the collagen fibers and as well as an increase in certain cellular components that cause the tendon to appear thickened with sonar imaging. This increased thickness reduces the stress of the tendon but causes the tendon to become more stiff. At this phase the tendon still has the potential to return to being a normal tendon. During this stage you may have pain before you start an activity that goes away during the activity as the muscles and tendons get warmer then returns again after the activity as you cool down.

Tendon Disrepair (stage two – failed healing)

If your attempts to offload the tendon are unsuccessful or you make no attempt to offload the tendon to allow it to return to its normal state then you will progress to this next stage in the tendinopathy continuum. During this phase the tendon adaptation that took place during the initial phase continues and also advances. During this phase we have separation of the collagen fibers and disorganisation of the cell matrix. There will also be increased vascularity and neural ingrowth in the tendon. The early stages of this phase are reversible but the later stages are not. Now you may find that the pain does not go away with activity and may actually start to get worse.

Degenerative tendinopathy (stage three – permanent damage)

This is the final stage of the golfer’s elbow tendinopathy continuum and has a very poor prognosis as the tendon adaptation and damage is now permanent and cannot return to a normal tendon. Imaging of this tendon shows that its cellular matrix is disorganized and there are areas of cell death. It also shows that the tendon is interspersed with areas in the degenerative phase with areas that are in the disrepair phase. During this stage you can expect to have a constant aching pain with an inability to perform activities with your affected hand due to pain. You will reach this stage if you ignore the warning signs and do not make any attempt to manage the load that is placed on the tendon. The risk of tearing the tendon or ulnar nerve neuropathy increases dramatically.

As physiotherapists we use various tests and palpation of the different muscles and tendons to make our diagnosis. We determine which muscles and tendons are involved by having you perform active, resisted and stretching movements to accurately determine the location of your pain as well as its severity.

This diagnostic procedure then provides us with all of the information that we need to create a clear clinical picture for your golfers’ elbow. We can then estimate your prognosis and create a fine tuned rehabilitation program to best address your muscles and tendon strength. We will monitor your progress to get you back to work or sport as quickly and safely as possible.

An x-ray does not show any muscle and tendons and will be of little diagnostic value for a golfer’s elbow. They are mainly used to identify bone related pathology such as fractures. We will only refer you for an x-ray if we feel it is necessary, for example if the tendon ruptured and suspect there may be some form of avulsion fracture.

Ultrasound is a quick and easy way that we can use to assess the current state of the muscles and tendons involved in a golfer’s elbow. It can identify if the tendon is thickened, any tears in the tendon or muscle, increased vascularity in the tendon as well as areas where the cellular matrix is disorganised or areas of cell death. This will allow us to more accurately estimates how long your recovery will take

In most cases an MRI isn’t needed for golfers’ elbow as ultrasound is sufficient. We will only consider referring for one if we suspect that there may be a larger or different problem that cannot be picked up with ultrasound.

Golfer’s elbows, like other tendinopathies, can take a long time to heal. Our tendons do not heal as fast as other structures in our bodies such as muscle as tendons have a poor blood supply. Tendons also take more time to respond to treatment and they do not like sudden changes in the amount of load they are placed under.

A crucial part of tendon healing is activity modification. As tendons do not like sudden changes to training volume, frequency or intensity it is important to modify these factors to an appropriate level and gradually build them up over time. This is most often done by simply decreasing how many times a week you play golf or decreasing the number of golf balls you hit in a single session at the driving range. If this load management is not done effectively the tendon will gradually get worse until the damage becomes irreversible or the tendon ruptures.

Waiting too long to get treatment

One of the most common problems we deal with is people that wait 3 – 6 months or even longer before seeking treatment for their golfer’s elbow. In this time more often than not they also continue training and overloading the tendon. This means by the time they get to us their tendons have already undergone structural changes becoming weaker and more susceptible to injury. It also leads to a longer recovery time.

Reliance on medication

Oftentimes patients will also rely on anti-inflammatory medications to mask the pain allowing them to work or play. The negative effects of this approach is that these medications interfere with the healing process meaning the tendon which already takes a long time to heal take even longer to heal.

Incomplete rehab process

Patients tend to stop their physiotherapy treatment too early before the problem has truly been resolved. After two to three weeks of pain management, patients feel much better. As a result patients believe that the issue has resolved and they no longer need rehab and return to their activities as per usual only to return after a few weeks with the same problem. What is important to note here is that our goal isn’t simply to rid you of your pain but rather to restore your tendon to a healthy state. The only way that we can truly clear your from rehabilitation is by testing and retesting your tendons strength and ability to transmit force, absorb and release energy.

Corticosteroid injections

Sometimes patients will get cortisone injections to help them with the pain of their golfer’s elbow. While this does help to decrease your pain it has a negative side effect that it actually weakens your tendons which has the potential to exacerbate the problem. Also the pain relieving effects are only temporary and if you do not address the cause of the problem your pain will quickly return. You may be tempted to go for another injection but be warned this runs the risk of leading to tendon rupture.

Resting

A common misconception that patients have is that if they rest their tendon until the pain goes away that the problem has been resolved. However this actually causes the tendon to become weaker meaning that when you return to activity it will actually take less activity to cause you pain than what it did to create the initial injury. Golfer’s elbows and tendinopathies in general are a load management problem. This means we actually have to continue exercising to address the problem rather than resting it. The trick here however is knowing what level of load and pain is appropriate to work or train at and not run the risk of further tissue damage.

As physiotherapists we are able to competently treat golfer’s elbows, with our main focus being on regaining the full strength of the tendon and restoring its abilities to transfer, store and release force. We have an important role to play in making sure that you don’t fall behind schedule in your rehab by monitoring your progress, preventing long term complications and providing you with the best possible outcomes for your treatment.

We employ a wide array of treatment modalities to achieve this goal. These range from electrotherapy modalities such as laser or ultrasound to assist with pain and stimulate healing. We make use of techniques such a rigid taping or kinesiology taping to protect the injured structures. Pain we can address with the techniques such as dry needling, myofascial release, joint or neural mobilisation to help support the recovery process. Throughout the healing process we will be there at your side, guiding you through your individualised rehabilitation program ensuring that you can get back to work and golf as soon and as safely as possible.

As tendons have a slow recovery rate you can expect your golfer’s elbow rehabilitation to take anywhere between 6 weeks and 3 months. Though this can vary from one patient to the next as rehab goals are achieved at different speeds between patients. The aim of the rehabilitation program is to go back to your normal routine as soon as possible but you expect a few flare ups along the way.

During the initial stages when your pain is still very acute we will see you twice a week to effectively assist with pain management and to monitor your progress. As your pain improves and we start with resistance exercises we will space your appointment to every 10 days and eventually every two weeks. This is to ensure that we can maintain a good intensity with your exercises and allow your tendon to become stronger as soon as possible.

• General practitioner (GP):

  can if needed prescribe you pain medication

• Cortisone injection: can be used to decrease your pain when it is more chronic and isn’t being relieved effectively via other methods however rehab is essential after the injection as the injection does nothing to solve the problem.
• Extracorporeal shock wave therapy: is a treatment option for pain that can be considered when your golfer’s elbow is new and steroid injections are not an option. However it should replace a well structured rehabilitation program.
• Biokineticist: can help you in the end stage of your rehabilitation after tissue healing has taken place. They can also help with long term maintenance by making sure that you continue to strengthen the tendon.
• Bracing: specifically neutral wrist or counterforce bracing to limit your wrist movements to help manage your symptoms but also cannot replace your rehabilitation program as it also does not strengthen your tendon.

Exercise to strengthen the tendon is considered the first line gold standard treatment for tendinopathy type injuries. Surgery should only be used as an absolute last resort if your golfer’s elbow has not responded to physiotherapy treatment at all for 3-12 months.

After the operation rehabilitation is essential to get you back on track as soon as possible. The process is also by no means quick. Physiotherapy in general starts 7-10 days after the operation, the first 3 – 4 weeks you will mainly focus on range of motion exercise of the wrist and elbow. You will start with resistance exercises at 6 weeks and in most cases only return to active 3 – 6 months after the operation.

• C6 and C7 radiculopathy or pinched nerves – in your neck – can cause pain that can travel down your arm and also affects the inside of your elbow. It can also cause numbness and tingling in your fingers as well as weakness in your hand.

• Osteoarthritis – can also cause pain in the medial part of your elbow that can get worse with repetitive forearm movements
• Flexor-pronator muscle strain – can cause pain on the medial aspect of the elbow when you are gripping or throwing objects as well as with bending and twisting movements of your forearm.
• Anterior interosseous nerve entrapment – will cause pain of your wrist and forearm, numbness in your first three fingers and make it difficult to make a fist.
• Lateral epicondylopathy (tennis elbow) – pain is more on the outside of the elbow. It will also be painful when you try to carry heavy objects or make a fist or with movements of your wrist and forearm.