Golfer’s Elbow Treatment By Physiotherapists
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 forearm muscles, which flex and rotate the forearm, originate in tendon-like tissue at the medial epicondyle, the bony lump on the inside part of the elbow. Due to the lack of inflammation the term tendonitis is not correct and tendinopathy, an internal process of degeneration, is the preferred term. Any activity which pushes the lower arm outwards away from the body, into so-called valgus or "knock elbow", puts extra force on the muscles of the flexor origin which are resisting the movement.
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.
Patients complain of aching pain over the front of the inner epicondyle, worse with repeated wrist flexion and better with rest. Pain can occur in the shoulder, elbow, forearm or hand, with weakness in the lower arm and hand also. The physiotherapist will examine the bony areas and joints of the elbow, check the muscles and their tendinous insertions. The physio palpates the ulnar nerve in the groove behind the elbow, called the "funny bone" when it’s hit. The nerve can give pins and needles or weakness in the forearm and a neurological examination excludes other causes of pain or weakness.
Most golfer’s elbow treatment is conservative, not surgical. Treatment involves activity modification, forearm or wrist splinting, anti-inflammatory drugs, steroid injections and physiotherapy. Modification of the use of the arm is vital to prevent ongoing stimulation of the condition, so altering the mechanics of swinging the golf club or other sporting equipment is essential. Patient education continues with the identification of aggravating activities and postures and the patient is taught to avoid them.
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.
Scientific work shows that steroid injections can be useful in the early stages of golfer’s elbow to reduce pain and the time to recovery, but they are also used in chronic situations. There is no evidence that shockwave or laser therapy has any effectiveness and surgery is contemplated when a significant period of physiotherapy has been attempted without success. The surgeon removes the abnormal tendinous tissue and if the ulnar nerve is involved he may move it around to the front of the elbow from its posterior groove.
A professional instructor will allow correction of golf swing technique. Overall fitness including strengthening exercises, aerobic work and stretching is another aim of treatment. Proper sporting technique and equipment usage is vital in athletes, with a good warm up prior to performance and good stretching afterwards. Patients may need to be strictly monitored and treated by the physiotherapist as many sports people ignore pain during activity, worsening or prolonging their symptoms.
Jonathan Blood Smyth is a Superintendent Physiotherapist at an NHS hospital in the South-West of the UK. He specialises in orthopaedic conditions and looking after joint replacements as well as managing chronic pain. Visit the website he edits if you are looking for physiotherapists in Manchester.