Golfers elbow

What is golfers elbow?

Golfers elbow is a relatively common overuse injury which typically causes pain at the inner aspect of the elbow. It is a similar condition to tennis elbow however affects the inner aspect of the elbow rather than the outer aspect.

The group of muscles at the front of the forearm are commonly called the forearm flexors (figure 1). These muscles act to flex the wrist and fingers (i.e. bend them forwards) and have a common bony attachment at the inner aspect of the elbow called the medial epicondyle (figure 1). The forearm flexors attach to the medial epicondyle via the flexor tendon.

During contraction of the forearm flexors, tension is placed through the flexor tendon at its attachment to the medial epicondyle. When this tension is excessive due to too much repetition or high force, damage to the tendon occurs. Golfers elbow is a condition whereby there is damage, with subsequent inflammation and degeneration to the flexor tendon at its bony attachment to the inner elbow. This is usually due to gradual wear and tear associated with overuse, however, it may also occur traumatically due to a specific incident.

Although this condition can occur at any age, it is commonly seen in patients between the ages of 40 and 60.

Causes of golfers elbow

Contrary to what the name suggests, you do not have to play golf to develop this condition. In fact, golfers elbow is more commonly seen in non-golf players than in golf players. Patients typically develop this condition due to activities involving repetitive wrist flexion against resistance or forceful or repetitive gripping of the hand. These activities may include sports or manual work such as:

• golf (especially those who continually take divots out of the ground)
• tennis (especially those players who put a lot of top spin on the ball)
• squash
• badminton
• water skiing
• gymnastics
• body building or weight lifting
• carpentry
• hammering
• painting
• chopping wood
• bricklaying
• repetitive use of a screwdriver
• sewing
• knitting
• working at a computer

It is also common for patients to develop this condition following a sudden increase in activities that place stress on the forearm flexors (such as involvement in a golf tournament over consecutive days) or due to a change in these activities (such as using a new technique or clubs, or hitting the ball too hard). In golf players, golfers elbow is often associated with poor swing technique.

Occasionally, this condition may develop suddenly. This is usually due to a forceful movement involving a heavy lifting or gripping force through the arm. In golf, this may occur when mis-timing a shot and taking a divot out of hard ground.

A history of wrist, elbow, shoulder or neck injury may increase the likelihood of a patient developing this condition.

Signs and symptoms of golfers elbow

The symptoms associated with golfers elbow usually develop gradually over a period of time. Initially, symptoms may present as an ache following an aggravating or unaccustomed activity. This may often be felt first thing in the morning. Patients with this condition usually experience localized elbow pain 1-2cm down from the bony lump on the inner aspect of the elbow (medial epicondyle – figure 1) that increases on firmly touching this region. Occasionally, the pain may radiate into the forearm.

In less severe cases of this condition, patients may only experience a minor ache. In more severe cases, the pain may be quite incapacitating and can keep the patient awake at night. Usually pain is experienced as an ache that increases to a sharper pain with activity. Occasionally, golfers elbow can be associated with neck, shoulder or upper back pain on the same side. In longstanding cases muscle weakness and reduced grip strength may also be present.

Patients with this condition often experience an increase in pain during everyday activities such as picking up a cup, turning a door knob, opening a jar, shaking hands, carrying groceries or turning the steering wheel of a car. Elbow stiffness may also be experienced and is typically worse first thing in the morning.

Diagnosis of golfers elbow

A thorough subjective and objective examination from a physiotherapist is usually sufficient to diagnose golfers elbow. Further investigations such as an MRI scan or Ultrasound may be required, in rare cases, to confirm diagnosis.

Treatment for golfers elbow

Most cases of golfers elbow settle well with appropriate physiotherapy. This includes careful assessment by the physiotherapist to determine which factors have contributed to the development of the condition, with subsequent correction of these factors.

The success rate of treatment for patients with this condition is largely dictated by patient compliance. One of the key components of treatment is that the patient rests sufficiently from ANY activity that increases their pain until they are symptom free. Activities which place large amounts of stress through the elbow and forearm should also be minimized, these include: gripping sports (such as golf, tennis, gymnastics, weight lifting etc.) gripping activities, carrying or lifting. Resting from aggravating activities ensures that the body can begin the healing process in the absence of further tissue damage. Once the patient can perform these activities pain free, a gradual return to these activities is indicated provided there is no increase in symptoms.

Ignoring symptoms or adopting a 'no pain, no gain' attitude is likely to lead to the problem becoming chronic. Immediate, appropriate treatment in patients with golfers elbow is essential to ensure a speedy recovery. Once the condition is chronic, healing slows significantly resulting in markedly increased recovery times.

Patients with this condition will usually benefit from following the R.I.C.E. Regime. The R.I.C.E regime is beneficial in the initial phase of the injury (first 72 hours) or when inflammatory signs are present (i.e. morning pain or pain with rest). This involves resting from aggravating activities, regular icing, the use of a compression bandage and keeping the arm elevated. Anti-inflammatory medication may also significantly hasten the healing process by reducing the pain and swelling associated with inflammation.

Patients with golfers elbow should perform pain-free flexibility and strengthening exercises as part of their rehabilitation to ensure an optimal outcome. The treating physiotherapist can advise which exercises are most appropriate for the patient and when they should be commenced. An eccentric strengthening program is often required to restore full strength and function to the elbow (especially in chronic cases).

A graduated return to activity or sport carefully monitored by a physiotherapist is required in the final stages of treatment. Often the use of a golfers elbow brace or support can assist during this phase of the rehabilitation process.

Prognosis of golfers elbow

With appropriate management, most minor cases of golfers elbow that have not been present for long can usually recover within a few weeks. In more severe and chronic cases recovery can be a lengthy process and may take up to 6 months in those who have had their condition for a long period of time. Early physiotherapy intervention is therefore vital to hasten recovery.

Contributing factors to the development of golfers elbow

There are several factors which can predispose patients to developing this condition. These need to be assessed and corrected with direction from a physiotherapist. Some of these factors include:

• excessive or inappropriate training or activity
• poor sporting technique or equipment
• muscle weakness
• joint tightness
• Medial collateral ligament instability
• muscle tightness
• inadequate warm-up
• Injury to the neck, shoulder, upper back or nerves that supply the elbow

Physiotherapy for golfers elbow

Physiotherapy treatment in patients with this condition is vital to hasten the healing process, ensure an optimal outcome and decrease the likelihood of future recurrence. Treatment may comprise:

• soft tissue massage
• electrotherapy (e.g. ultrasound)
• taping or bracing
• joint mobilization
• neural stretching
• dry needling
• ice or heat treatment
• progressive exercises to improve flexibility and strength
• postural correction
• treatment of any related injuries (especially neck, shoulder or upper back conditions)
• education
• training and activity modification advice
• technique correction (such as tennis forehand or golf swing technique)
• anti-inflammatory advice
• an appropriate return to sport or activity plan

Other intervention for golfers elbow

Despite appropriate physiotherapy management, some patients with golfers elbow do not improve. When this occurs the treating physiotherapist or doctor can advise on the best course of management. This may include X-rays, ultrasound or MRI investigations, pharmaceutical intervention, corticosteroid injection, autologous blood injection or referral to appropriate medical authorities who can advise on any intervention that may be appropriate to improve the condition. In very rare chronic cases, surgical intervention may be considered.

Exercises for golfers elbow

The following exercises are commonly prescribed to patients with golfers elbow. You should discuss the suitability of these exercises with your physiotherapist prior to beginning them. Generally, they should be performed 3 times daily and only provided they do not cause or increase symptoms.

Golfers Elbow Stretch

Begin this exercise with your elbow straight (figure 2). Take your wrist backwards using your other hand until you feel a mild to moderate stretch pain-free. Hold for 15 seconds and repeat 4 times.

Figure 2 – Golfers Elbow Stretch (right side)

Tennis Ball Squeeze

Begin this exercise holding a tennis ball (figure 3). Squeeze the tennis ball as hard as possible and comfortable without pain. Hold for 5 seconds and repeat 10 times.

Figure 3 – Tennis Ball Squeeze (right hand)