Golfer's Elbow

Rheumatology

Clinicals - History

Fact Explanation
Pain of insidious onset on the medial aspect of the elbow; usually on the dominant side The pain can range from mild discomfort to a severe ache.

It is due to the initial inflammation, or a subsequent complication such as angio-fibroblastic degeneration, or tendinosis of the medial musculo-tendinous unit.
Pain of insidious onset on the medial aspect of the elbow; usually on the dominant side
The pain can range from mild discomfort to a severe ache.

It is due to the initial inflammation, or a subsequent complication such as angio-fibroblastic degeneration, or tendinosis of the medial musculo-tendinous unit.
Pain radiating to the forearm The affected musculo-tendinous unit is continuous with the flexor pronator muscles (i.e. Pronator teres and Flexor carpi radialis) of the forearm. Pain radiating to the forearm
The affected musculo-tendinous unit is continuous with the flexor pronator muscles (i.e. Pronator teres and Flexor carpi radialis) of the forearm.
Worsening of pain with gripping and twisting movements Occurs upon opening a jar, turning a door handle, lifting or throwing objects.

The valgus stress transmits to the muscles attached during forearm pronation and wrist flexion. There may be associated micro tears as well.
Worsening of pain with gripping and twisting movements
Occurs upon opening a jar, turning a door handle, lifting or throwing objects.

The valgus stress transmits to the muscles attached during forearm pronation and wrist flexion. There may be associated micro tears as well.
Limited range of movements Due to flexion contractures; relatively late presentation. Limited range of movements
Due to flexion contractures; relatively late presentation.
Weakness of grip Occurs to pain on gripping. Weakness of grip
Occurs to pain on gripping.
Numbness and tingling of ring and little fingers Concurrent ulnar neuritis. Numbness and tingling of ring and little fingers
Concurrent ulnar neuritis.

Clinicals - Examination

Fact Explanation
Point tenderness over the Pronator teres and Flexor carpi ulnaris origin at the medial epicondyle. Initial Inflammation or subsequent pathologies. Point tenderness over the Pronator teres and Flexor carpi ulnaris origin at the medial epicondyle.
Initial Inflammation or subsequent pathologies.
Elbow flexion test. Positive if there is co-existent ulnar neuritis. Elbow flexion test.
Positive if there is co-existent ulnar neuritis.
Warmth and swelling over the medial epicondyle. Underlying inflammatory process. Warmth and swelling over the medial epicondyle.
Underlying inflammatory process.
Tinel’s sign Positive if there is co-existent ulnar neuritis. Tinel’s sign
Positive if there is co-existent ulnar neuritis.
Pain on flexion against resistance Occurs in chronic cases due to development of flexion contractures. Pain on flexion against resistance
Occurs in chronic cases due to development of flexion contractures.

Investigations - Diagnosis

Fact Explanation
Plain X-Ray of the elbow Usually no abnormalities are noted. Therefore imaging is not essential in the initial evaluation. But 20%-25% of patients with Golfer's elbow can have soft tissue calcification of the epicondyle. In chronic cases (e.g. sportsmen); traction spurs and medial collateral ligament calcification may be seen. Valgus instability is detected by valgus stress radiographs; medial joint line opening greater than 3 mm qualifies as positive. Plain X-Ray of the elbow
Usually no abnormalities are noted. Therefore imaging is not essential in the initial evaluation. But 20%-25% of patients with Golfer's elbow can have soft tissue calcification of the epicondyle. In chronic cases (e.g. sportsmen); traction spurs and medial collateral ligament calcification may be seen. Valgus instability is detected by valgus stress radiographs; medial joint line opening greater than 3 mm qualifies as positive.
Electromyography (EMG) Indicated in those with neurological symptoms. Electromyography (EMG)
Indicated in those with neurological symptoms.
Magnetic resonance imaging (MRI) Intra-tendinous thickening and increased signal intensity is seen in tendonitis. A tendon tear is detected by a fluid signal intensity gap between the tendon and the epicondyle. In addition, MRI arthrography is useful for evaluating rupture of the Ulnar collateral ligament. Magnetic resonance imaging (MRI)
Intra-tendinous thickening and increased signal intensity is seen in tendonitis. A tendon tear is detected by a fluid signal intensity gap between the tendon and the epicondyle. In addition, MRI arthrography is useful for evaluating rupture of the Ulnar collateral ligament.
Ultra Sound Scan Tears appear as hypo-echoic areas. Will also detect
calcifications.
Ultra Sound Scan
Tears appear as hypo-echoic areas. Will also detect
calcifications.

Investigations - Management

Fact Explanation
MRI Mild tendinosis (low-grade partial tear) appears on MRI as tendon thickening and increased internal signal intensity. Less than 20% of the entire tendon thickness is affected.

Moderate tendinosis (intermediate-grade partial tear) appears as partial-thickness tear with thinning and focal disruption that does not extend across the full thickness of the tendon. 20% - 80% of the entire tendon thickness is affected.

Severe tendinosis (high grade partial tear or full-thickness tear) is a near-complete or complete tear, characterized as a fluid-filled gap separating the tendon from its origin at the
lateral epicondyle. More than 80% of the tendon thickness is affected.
MRI
Mild tendinosis (low-grade partial tear) appears on MRI as tendon thickening and increased internal signal intensity. Less than 20% of the entire tendon thickness is affected.

Moderate tendinosis (intermediate-grade partial tear) appears as partial-thickness tear with thinning and focal disruption that does not extend across the full thickness of the tendon. 20% - 80% of the entire tendon thickness is affected.

Severe tendinosis (high grade partial tear or full-thickness tear) is a near-complete or complete tear, characterized as a fluid-filled gap separating the tendon from its origin at the
lateral epicondyle. More than 80% of the tendon thickness is affected.
Ultrasound Scan (USS) Mild tendinosis appears as a small linear hypo-echoic region at Extensor Carpi Radialis Brevis (ECRB) origin suggestive of a small partial thickness tear.

Moderate tendinosis appears as a linear hypo-echoic region suggesting a partial thickness tendon tear surrounding heterogeneous echogenicity indicative of associated tendinitis (arrow).

Severe tendinosis appears as a large hypo-echoic region at the tendon origin, a finding indicative of a near-full thickness tear with distal linear foci of calcium deposition and marked heterogeneity
Ultrasound Scan (USS)
Mild tendinosis appears as a small linear hypo-echoic region at Extensor Carpi Radialis Brevis (ECRB) origin suggestive of a small partial thickness tear.

Moderate tendinosis appears as a linear hypo-echoic region suggesting a partial thickness tendon tear surrounding heterogeneous echogenicity indicative of associated tendinitis (arrow).

Severe tendinosis appears as a large hypo-echoic region at the tendon origin, a finding indicative of a near-full thickness tear with distal linear foci of calcium deposition and marked heterogeneity

Management - Supportive

Fact Explanation
Avoiding offending activities To prevent exerting more force over the affected area. Of note however, complete immobilization or inactivity should be avoided, as this can lead to disuse atrophy and compromise later rehabilitation. Avoiding offending activities
To prevent exerting more force over the affected area. Of note however, complete immobilization or inactivity should be avoided, as this can lead to disuse atrophy and compromise later rehabilitation.
Icing for 20 minutes, 3 to 4 times a day Local vasoconstrictive and analgesic effects.
Best done after completing exercise, stretching, and strengthening.
Icing for 20 minutes, 3 to 4 times a day
Local vasoconstrictive and analgesic effects.
Best done after completing exercise, stretching, and strengthening.
Elbow braces (e.g.: counter-force bracing and cock up wrist splints.) Counter-force bracing is used during activity that involve movements of the elbow and theoretically decreases the contraction forces. Cock-up wrist splints maintain neutral position. Elbow braces (e.g.: counter-force bracing and cock up wrist splints.)
Counter-force bracing is used during activity that involve movements of the elbow and theoretically decreases the contraction forces. Cock-up wrist splints maintain neutral position.

Management - Specific

Fact Explanation
Oral Non Steroidal Anti Inflammatory Drugs (NSAIDs) for 10-14 days Provides pain relief and anti inflammatory effect. Since epicondylitis is considered a degenerative process, the beneficial effects of anti-inflammatory drugs is due to relieving
pain caused by synovitis.

If the symptoms improve but without complete relief; a second course of medication can be started after a brief period of
abstinence. Topical NSAID applications can be used in addition to oral drugs.
Oral Non Steroidal Anti Inflammatory Drugs (NSAIDs) for 10-14 days
Provides pain relief and anti inflammatory effect. Since epicondylitis is considered a degenerative process, the beneficial effects of anti-inflammatory drugs is due to relieving
pain caused by synovitis.

If the symptoms improve but without complete relief; a second course of medication can be started after a brief period of
abstinence. Topical NSAID applications can be used in addition to oral drugs.
Local corticosteroid injection around the tendon insertion Steroid injections are efficacious in the short term. It provides significantly less pain at 6 weeks but no difference at 3 months and 1 year. Local corticosteroid injection around the tendon insertion
Steroid injections are efficacious in the short term. It provides significantly less pain at 6 weeks but no difference at 3 months and 1 year.
Autologous blood injection or platelet-rich plasma (PRP) injection. This is a novel method of treatment for refractory cases of medial epicondylitis. It is thought to transform growth factor-b and basic fibroblast growth factor carried in the blood, which act as humoral mediators to induce the healing cascade. Autologous blood injection or platelet-rich plasma (PRP) injection.
This is a novel method of treatment for refractory cases of medial epicondylitis. It is thought to transform growth factor-b and basic fibroblast growth factor carried in the blood, which act as humoral mediators to induce the healing cascade.
Extracorporeal shock wave therapy (ESWT) Provides relief by Increasing neo-vascularization, and modulate release of endogenous nitric oxide (NO) Extracorporeal shock wave therapy (ESWT)
Provides relief by Increasing neo-vascularization, and modulate release of endogenous nitric oxide (NO)
Elastic Therapeutic Tape Improves the contraction of the damaged muscle and uses the elasticity to create folds in the skin, resulting in areas of low pressure and areas of high pressure leading to a change in the flow of fluid under the skin, which will improve circulation of blood and lymph thereby reducing inflammatory reaction and pain. In addition, causes neurological suppression to reduce pain and increase range of motion of the joint. Elastic Therapeutic Tape
Improves the contraction of the damaged muscle and uses the elasticity to create folds in the skin, resulting in areas of low pressure and areas of high pressure leading to a change in the flow of fluid under the skin, which will improve circulation of blood and lymph thereby reducing inflammatory reaction and pain. In addition, causes neurological suppression to reduce pain and increase range of motion of the joint.
Guided rehabilitation program with stretching and progressive isometric muscle contraction. Achieving muscle strength greater than the pre-injury level is the goal, because of the risk of recurrent tension overload at pre-injury strength. Guided rehabilitation program with stretching and progressive isometric muscle contraction.
Achieving muscle strength greater than the pre-injury level is the goal, because of the risk of recurrent tension overload at pre-injury strength.
Percutaneous epicondylar release Surgery is considered when non surgical options have failed to produce results for 3-6 years.
Percutaneous epicondylar release has a higher rate of success when compared to other surgical options. It is relatively simple to perform and is done as an outpatient procedure.
Percutaneous epicondylar release
Surgery is considered when non surgical options have failed to produce results for 3-6 years.
Percutaneous epicondylar release has a higher rate of success when compared to other surgical options. It is relatively simple to perform and is done as an outpatient procedure.
Epicondylectomy This is an outpatient a procedure, performed under general or regional anesthesia. The principle is removal of the medial epicondyle to alleviate compression of the ulnar nerve. Medial epicondylectomy can also be used to treat cubital tunnel syndrome. Epicondylectomy
This is an outpatient a procedure, performed under general or regional anesthesia. The principle is removal of the medial epicondyle to alleviate compression of the ulnar nerve. Medial epicondylectomy can also be used to treat cubital tunnel syndrome.

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