The weather is getting nice and people are already hitting the green and getting back into the swing of things, literally. One injury we see in golfers is called medial epicondylitis, or golfer’s elbow (GE). In athletics, it is also seen in throwers, rock climbers, bowlers, and weightlifters. GE is primarily caused by repetitive eccentric loading of the wrist flexors and/or forearm pronators, coupled with valgus overload at the elbow. A valgus force is one where the lower arm moves away from the body while the upper arm stays in close (so imagine “knock knees”, but in the arms). With golf, the intense valgus force at the elbow occurs during the late phase of the golf swing just before and during contact with the ball. This same valgus force occurs during the late cocking phase of throwing, which is why this is also called thrower’s elbow. Simultaneous wrist flexion and/or forearm pronation during ball release may produce even greater stress on the tendon, which is why technique matters. Medial epicondylitis is also seen in the general population in careers requiring repetitive upper extremity use, such as carpenters, massage therapists, utility workers, and butchers.
Golfer’s elbow is a chronic tendinosis of the flexor-pronator muscle group, right where it inserts on the medial epicondyle of the humerus. The flexor-pronator muscle group is composed of the pronator teres (which pronates or turns the forearm down) and common flexors of the wrist and hand, including flexor carpi radialis, flexor carpi ulnaris, flexor digitorum superficialis, and palmaris longus. With GE, the tendons of the flexor carpi radialis and pronator teres are the most commonly involved. The inside ligament of the elbow, called the ulnar collateral ligament (UCL), also attaches to the medial epicondyle. Together, the UCL and the common flexor tendon provide stability against flexion and valgus forces at the elbow.
Just like lateral epicondylitis or tennis elbow, medial epicondylitis or GE is considered a chronic tendinosis as opposed to an acutely inflamed tendinitis. There are four proposed stages of epicondylar tendinosis:
- Generalized inflammation – friction causing inflammation of tendon
- Angiofibroblastic degeneration – weakening of the tendon
- Structural failure – microtearing of tendon
- Fibrosis/calcification – failed reparation process which yields scar tissue
People with GE usually present with pain at the medial aspect or inside of the elbow. It is worse with activities, especially gripping, flexing the wrist, pronating the forearm, and throwing. Pain usually comes on gradually, but can be sudden if caused by trauma. Occasionally the pain radiates into the forearm and wrist. Some people may complain of associated numbness in the lateral wrist and last two fingers secondary to impingement of the ulnar nerve at the elbow. Often, there is tenderness to touch roughly 0.5-1 cm below or distal to the medial epicondyle. Symptoms are normally relieved by rest. Pain is aggravated by resisted wrist flexion and pronation.
Treatment of GE begins with rest. People should refrain from activities that exacerbate the symptoms, particularly repetitive wrist flexion, forearm pronation, and valgus stress at the elbow. Kinesiotape is useful to limit the maximum contractile force generated by the flexor-pronator muscle group. Once acute symptoms are alleviated, the focus turns to stretching and strengthening. Each phase of rehab requires targeted exercises with increasing repetition and speed. Initially, motion of the wrist and elbow is emphasized with non-weight bearing exercises and self-directed stretching. Once pain-free range of motion is achieved, tendon rebuilding and strengthening begins. Concentric open and closed chain exercises are used, increasing in weight and repetitions as tolerated. Finally, eccentric strengthening is implemented. A popular exercise that has been shown to treat chronic GE is the Reverse Tyler Twist. A rubber bar is held at one end near the chest with the involved hand, palm facing the body and wrist fully flexed. The other end of the bar is grasped by the uninvolved hand, at the other end of the bar, from above with the palm facing out. The rubber bar is then twisted by bringing the uninvolved elbow down so both palms are facing in. The arms are then brought in front of the body by straightening the elbows, while maintaining the twist in the rubber bar by maintaining full flexion of the involved wrist and extending the uninvolved wrist. The bar is slowly untwisted by moving only the involved wrist and hand back towards neutral. This slow, controlled motion provides an eccentric strengthening and lengthening component to the flexor-pronator group and its common tendon.
For golfers, equipment and technique should be addressed to reduce undue stress at the elbow. When selecting golf clubs, the length, shaft weight, club head weight, and club head strike zone must be considered. Golfer’s elbow is often found in the trail arm. Stress on the pronator teres of the trail arm is more often seen in amateur golfers than in pros, who use the lead arm in a protective manner to obtain optimum swing speed and power without excessive stress. Strengthening of the shoulder girdle and scapular stabilizers is key. Core and lower body strengthening may also aid in golfing mechanics, to relieve stress at the elbow when return to sport is allowed. Please be sure to check out Lara’s Golf Series on LYT Daily, where you can be sure to find the best prescription for your body! The Series is also available for purchase if you aren’t a LYT Daily subscriber! Happy golfing everyone!