Golfer's elbow is also known as medial epicondylitis and is the less common sister condition of tennis elbow, both conditions sharing the tendon degenerative nature without inflammation. They are referred to as tendinopathies due to the pathological changes which occur inside the tendon without an inflammatory process. Not just occurring in golfers, golfer's elbow also appears in racquet sports, cricket bowling, weightlifting and archery.



The muscles which flex and rotate the forearm originate over the medial epicondyle, the bony prominence on the inside of the elbow, with the tendon anchored into the bone by the tendinous insertion. The pain occurs close to this and may be due to a degenerative process occurring in the tendon, as little inflammation has been noted in these cases.

The throwing the ball action brings these factors into play, especially cocking the wrist at the start of the movement and the acceleration which follows. Golfers, whose dominant hand is typically affected, engage these stresses from the top of the backswing down to just before ball strike. Heavy topspin tennis players are also more susceptible.

Tennis elbow is more common but golfer's elbow remains the most reported pain problem over the inner elbow. Men are more likely to be sufferers than women in a 2:1 proportion, with most people affected in their early adult or middle years. The dominant hand is typically affected in two-thirds of cases, a third report a sudden pain onset with pain coming on slowly over time in the rest.

Pain and ache over the front of the medial epicondyle is the typical symptom, worse with repeated flexion of the wrist and improved with resting. Shoulder, elbow, forearm or hand pain can occur, with weakness or pins and needles in the lower arm. Physiotherapy examination includes the bony tendon insertions, the elbow joints and the muscles, with palpation of the "funny bone" area behind the elbow where the ulnar nerve lies. Nerve involvement can give weakness in the forearm muscles and sensory symptoms, so an exclusion neurological examination is performed by the physio.

Conservative, non-surgical, treatment is the mainstay of management. This includes physiotherapy, anti-inflammatory drugs, wrist splints and steroid injections. Patient education is important and activity modification is the first line of treatment, reducing the frequency of aggravating episodes. Altering the mechanics of the golf swing or other activity is vital if the area is to be allowed to settle. The patient avoids certain activities with the affected muscles and avoids leaning on the elbow.

In the acute phase of golfer's elbow the physiotherapist's aim is to reduce any pain and inflammation using ice treatment, stretching gently, deep frictions, ultrasound and anti-inflammatory medication. Progression into the sub acute phase changes treatment to increasing flexibility, strength and returning to normal activities in a paced manner. Counterforce forearm bracing can help realign the tendon stresses, or a wrist brace can give the muscles a rest. For a chronic syndrome the treatment is similar with reducing splint use and returning to sporting activities.

Doctors inject corticosteroid medication into the sites of chronic golfer's elbow but this treatment appears to be more useful in the earlier, acute cases. Other therapies, such as shockwave or laser, have been used but do not seem to be effective. Once physio has been attempted for some time without improvement then a surgical approach may be considered, cutting out the abnormal tissue from the tendon. The ulnar nerve can be transposed around to the front of the joint from its position in the groove posteriorly.

Advice from a professional instructor is well worthwhile as they can instruct on technique of the golf swing, aerobic fitness, muscle strength work and flexibility. Warming up prior to activity and stretching afterwards, with good sporting technique and sound choice of equipment are the basic requirements. Monitoring of patients by the physiotherapist, especially if they are sports people, may be essential to avoid overdoing and training or performing through pain.