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Medial Epicondylitis (Golfer's Elbow)

What is Golfer's Elbow?

  • Golfer's elbow, also known as medial epicondylitis, is a condition characterized by pain and tenderness on the inner side of the elbow, where the tendons of the forearm muscles attach to the bony prominence of the medial epicondyle.
    • This condition is typically caused by repetitive stress or overuse of the wrist flexor and pronator muscles, leading to tendinosis of the common flexor tendon [Alrabaa et al, 2020; Jobe & Coccotti, 1994; Amin et al, 2015].
    • Patients with golfer's elbow often report medial-sided elbow pain that worsens with activities involving wrist flexion and forearm pronation, such as gripping or lifting objects.
    • The pain may also be exacerbated during the late cocking or early acceleration phases of the throwing motion in athletes [Jobe & Coccotti, 1994; Amin et al, 2015].

How is Golfer's Elbow diagnosed?

  • Golfer's elbow, also known as medial epicondylitis, is primarily diagnosed clinically.

    • Patients typically report pain and tenderness over the medial
      epicondyle, which is exacerbated by activities involving wrist flexion and forearm pronation.

    • Specific physical examination maneuvers, such as resisted wrist flexion and forearm pronation, can reproduce the pain and help localize the condition [Kane et al, 2014; Chumbley et al, 2000].

  • Imaging studies include:

    • Ultrasonography: Ultrasonography is a valuable initial imaging modality for diagnosing medial epicondylitis. Ultrasonography has shown high sensitivity (95.2%) and specificity (92%) for detecting medial epicondylitis [Park et al, 2008].

    • Magnetic Resonance Imaging (MRI): MRI is particularly useful for chronic cases or when surgical intervention is considered. It provides detailed images of the common flexor tendon and can identify signal changes, tendon thickening, and associated soft tissue edema. The American College of Radiology notes that MRI has high sensitivity (90-100%) and specificity (83-100%) for diagnosing epicondylalgia [Bae et al, 2021; Thomas et al, 2022].

What are the treatments for golfer's elbow?

Conservative Management

  • The treatment options for golfer's elbow, also known as medial epicondylitis, encompass a range of nonoperative and operative strategies. In the majority of cases, golfer's elbow resolves over time with conservative management, including physical therapy, non-steroidal anti-inflammatory medications (i.e. Motrin, ibuprofen, Aleve, naproxen), and injections.
    • Activity Modification: Reducing or avoiding activities that exacerbate symptoms is crucial. This allows the tendon to heal and prevents further injury [Jobe & Coccotti, 1994; Prabhakar et al, 2023].
    • Nonsteroidal Anti-Inflammatory Drugs (NSAIDs): Both topical and oral NSAIDs have moderate evidence of modest efficacy [Hegmann et al, 2013]
    • Physical Therapy: A structured rehabilitation program focusing on stretching and strengthening exercises for the flexor-pronator mass is essential. This includes eccentric exercises, which have shown effectiveness in tendon rehabilitation [Jobe & Coccotti, 1994; Amin et al, 2015].


  • Corticosteroid Injections: These can provide short-term pain relief, although their long-term benefits are less clear. They should be used cautiously due to potential adverse effects with repeated use [Amin et al, 2015].
  • Prolotherapy: Involves injecting an irritant solution, typically hypertonic dextrose, into the site of tendinopathy to promote tissue repair and pain relief. The evidence supporting the use of prolotherapy for treating golfer's elbow (medial epicondylitis) is evolving, with several studies indicating potential benefits.
    • A review by Dwivedi et al. highlights the utility of prolotherapy for upper extremity pathologies, including medial epicondylitis, suggesting it can be a safe and effective non-surgical treatment option [Dwivedi et al, 2019].
    • Another review by Distel and Best discusses the role of prolotherapy in treating chronic musculoskeletal pain, including refractory tendinopathies, and notes that while there is growing evidence for its efficacy, further high-quality randomized controlled trials are needed to establish definitive protocols and indications [Distel & Best, 2011].
    • Prabhakar et al. mention prolotherapy as an intermediate intervention for medial elbow pain syndrome, including medial epicondylitis, when initial conservative treatments fail [Prabhakar et al, 2023].
    • Hsu et al. provide a narrative review indicating that prolotherapy can be beneficial for various tendinopathies, including lateral epicondylosis, which shares pathophysiological similarities with medial epicondylitis [Hsu et al, 2023].
  • Platelet-rich plasma (PRP) and autologous blood injections have
    conflicting evidence regarding their efficacy with some studies showing benefit and others not. Learn more about PRP HERE.
    • A systematic review and meta-analysis by Huang et al. found that PRP injections provide statistically and clinically meaningful long-term improvement in pain for elbow epicondylitis compared to corticosteroid injections, with a very large effect size. This suggests that PRP may be more effective than corticosteroids for long-term pain relief [Huang et al, 2020].
    • Annaniemi et al. conducted a comparative study with long-term follow-up and found that patients receiving PRP injections for chronic epicondylitis had significantly better pain and functional outcomes compared to those continuing with physical therapy and pain medication. The PRP group also required fewer surgical procedures [Annaniemi et al, 2022].
    • Hechtman et al. reported that a single PRP injection significantly reduced pain and improved function in patients with recalcitrant epicondylitis, with a 90% success rate in reducing worst pain by at least 25% at follow-up [Hechtman et al, 2011].
    • Mishra and Pavelko's cohort study demonstrated that PRP injections led to significant pain reduction and functional improvement in patients with chronic elbow tendinosis, with an 81% improvement in pain scores at 6 months and a 93% reduction in pain at final follow-up [Mishra and Pavelko, 2006].
    • Some studies have shown less definitive results. For instance, Montalvan et al. found no significant difference between PRP and saline injections for recent epicondylitis in terms of pain reduction and functional improvement at 6 and 12 months [Montalvan et al, 2015].
  • Extracorporeal Shock Wave Therapy (ESWT): The evidence for Shock Wave Therapy in the treatment of lateral epicondylitis (tennis elbow) is mixed but generally supports its efficacy, particularly for pain relief and grip strength recovery.
    • A systematic review by Testa et al. concluded that ESWT is a safe and effective treatment for upper limb tendinopathies, including medial epicondylitis, with positive clinical outcomes in many cases [Testa et al, 2020].
    • Another systematic review by Rhim et al. found that ESWT may be effective for various sports-related injuries, including medial epicondylitis, and is generally well-tolerated with minimal side effects [Rhim et al, 2024].
    • Notarnicola et al. conducted a prospective observational study and found significant improvements in pain and functional scores (measured by the Visual Analogue Scale and Mayo Elbow Performance Index) in patients with epicondylitis following ESWT, although no significant changes in handgrip strength were observed [Notarnicola et al, 2014].
    • Krischek et al. reported less favorable outcomes, with only a minority of patients achieving excellent or good results at one-year follow-up, raising questions about the overall efficacy of ESWT for medial epicondylitis [Krischek et al, 1999].

Operative treatments

Surgery is considered for refractory cases that do not respond to nonoperative measures:

  • Open Surgical Techniques: This is the most commonly performed procedure and involves the debridement of the diseased tendon tissue, followed by repair and reattachment of the flexor-pronator origin. The procedure can be performed with or without the use of suture anchors. Studies have shown significant improvements in pain and function postoperatively, with high success rates and low complication rates [Arevalo et al, 2023; Vinod & Ross, 2015].
  • Tenotomy under Ultrasound Guidance using the TENEX device: The evidence for the use of ultrasound-guided tenotomy, including the Tenex system, in the treatment of lateral epicondylitis (tennis elbow) is generally supportive, particularly for patients with refractory symptoms.Learn more about TENEX HERE.
    • A systematic review by Shomal Zadeh et al. found that tenotomy under ultrasound guidance, including Tenex, is effective for chronic tendinopathy, providing similar outcomes to surgical tenotomy with fewer complications [Shomal Zadeh et al, 2023].
    • Another meta-analysis by Shomal Zadeh et al. demonstrated significant pain and function improvement at short-, intermediate-, and long-term follow-ups, supporting tenotomy under ultrasound guidance as a viable treatment option [Shomal Zadeh et al, 2023].
    • Boden et al. compared PRP injections to the Tenex procedure and found both treatments to be equally effective in improving pain and function in patients with medial and lateral epicondylitis [Boden et al, 2019].
    • Barnes et al. reported significant improvements in pain and function scores at 12 months post-procedure with no complications [Barnes et al, 2015].

REFERENCES

  1. Alrabaa RG, Dantzker N, Ahmad CS. Injuries and Conditions Affecting the Elbow Flexor/Pronator Tendons. Clin Sports Med. 2020 Jul;39(3):549-563.
  2. Amin NH, Kumar NS, Schickendantz MS. Medial epicondylitis: evaluation and management. J Am Acad Orthop Surg. 2015 Jun;23(6):348-55.
  3. Annaniemi JA, Pere J, Giordano S. Platelet-Rich Plasma Injections Decrease the Need for Any Surgical Procedure for Chronic Epicondylitis versus Conservative Treatment-A Comparative Study with Long-Term Follow-Up. J Clin Med. 2022 Dec 23;12(1):102.
  4. Arevalo A, Rao S, Willier DP 3rd, Schrock CI, Erickson BJ, Jack RA 2nd, Cohen SB, Ciccotti MG. Surgical Techniques and Clinical Outcomes for Medial Epicondylitis: A Systematic Review. Am JSports Med. 2023 Jul;51(9):2506-2515.
  5. Bae KJ, Park C, Ahn JM, Kang Y, Gong HS. Magnetic resonance imaging evaluation of patients with clinically diagnosed medial EBarnes DE, Beckley JM, Smith J. Percutaneous ultrasonic tenotomy for chronic elbow tendinosis: a prospective study. J Shoulder Elbow Surg. 2015 Jan;24(1):67-73.
  6. picondylitis. Skeletal Radiol. 2021 Aug;50(8):1629-1636.
  7. Boden AL, Scott MT, Dalwadi PP, Mautner K, Mason RA, Gottschalk MB. Platelet-rich plasma versus Tenex in the treatment of medial and lateral epicondylitis. J Shoulder Elbow Surg. 2019 Jan;28(1):112-119.
  8. Chumbley EM, O'Connor FG, Nirschl RP. Evaluation of overuse elbow injuries. Am Fam Physician. 2000 Feb 1;61(3):691-700.
  9. Distel LM, Best TM. Prolotherapy: a clinical review of its role in treating chronic musculoskeletal pain. PM R. 2011 Jun;3(6 Suppl 1):S78-81.
  10. Dwivedi S, Sobel AD, DaSilva MF, Akelman E. Utility of Prolotherapy for Upper Extremity Pathology. J Hand Surg Am. 2019 Mar;44(3):236-239.
  11. Hechtman KS, Uribe JW, Botto-vanDemden A, Kiebzak GM. Platelet-rich plasma injection reduces pain in patients with recalcitrant epicondylitis. Orthopedics. 2011 Jan 1;34(2):92.
  12. Hsu C, Vu K, Borg-Stein J. Prolotherapy: A Narrative Review of Mechanisms, Techniques, and Protocols, and Evidence for Common Musculoskeletal Conditions. Phys Med Rehabil Clin N Am. 2023 Feb;34(1):165-180.
  13. Huang K, Giddins G, Wu LD. Platelet-Rich Plasma Versus Corticosteroid Injections in the Management of Elbow Epicondylitis and Plantar Fasciitis: An Updated Systematic Review and Meta-analysis. Am J Sports Med. 2020 Aug;48(10):2572-2585.
  14. Jobe FW, Ciccotti MG. Lateral and Medial Epicondylitis of the Elbow. J Am Acad Orthop Surg. 1994 Jan;2(1):1-8.
  15. Kane SF, Lynch JH, Taylor JC. Evaluation of elbow pain in adults. Am Fam Physician. 2014 Apr 15;89(8):649-57.
  16. Krischek O, Hopf C, Nafe B, Rompe JD. Shock-wave therapy for tennis and golfer's elbow--1 year follow-up. Arch Orthop Trauma Surg. 1999;119(1-2):62-6.
  17. Mishra A, Pavelko T. Treatment of chronic elbow tendinosis with buffered platelet-rich plasma. Am J Sports Med. 2006 Nov;34(11):1774-8.
  18. Montalvan B, Le Goux P, Klouche S, Borgel D, Hardy P, Breban M. Inefficacy of ultrasound-guided local injections of autologous conditioned plasma for recent epicondylitis: results of a double-blind placebo-controlled randomized clinical trial with one-year follow-up. Rheumatology (Oxford). 2016 Feb;55(2):279-85.
  19. Notarnicola A, Quagliarella L, Sasanelli N, Maccagnano G, Fracella MR, Forcignanò MI, Moretti B. Effects of extracorporeal shock wave therapy on functional and strength recovery of handgrip in patients affected by epicondylitis. Ultrasound Med Biol. 2014 Dec;40(12):2830-40.
  20. Park GY, Lee SM, Lee MY. Diagnostic value of ultrasonography for clinical medial epicondylitis. Arch Phys Med Rehabil. 2008 Apr;89(4):738-42.
  21. Prabhakar G, Kanawade V, Ghali AN, Dutta AK, Brady CI, Morrey BF. Medial Elbow Pain Syndrome: Current Treatment Strategies. Orthopedics. 2023 Mar-Apr;46(2):e81-e88.
  22. Rhim HC, Shin J, Kang J, Dyrek P, Crockett Z, Galido P, Wade C, Hollander K, Borg-Stein J, Sampson S, Tenforde AS. Use of extracorporeal shockwave therapies for athletes and physically active individuals: a systematic review. Br J Sports Med. 2024 Feb 7;58(3):154-163.
  23. Shomal Zadeh F, Shafiei M, Hosseini N, Alipour E, Cheung H, Chalian M. The effectiveness of percutaneous ultrasound-guided needle tenotomy compared to alternative treatments for chronic tendinopathy: a systematic review. Skeletal Radiol. 2023 May;52(5):875-888.
  24. Shomal Zadeh F, Shafiei M, Shomalzadeh M, Pierce J, Thurlow PC, Chalian M. Percutaneous ultrasound-guided needle tenotomy for treatment of chronic tendinopathy and fasciopathy: a meta-analysis. Eur Radiol. 2023 Oct;33(10):7303-7320.
  25. Testa G, Vescio A, Perez S, Consoli A, Costarella L, Sessa G, Pavone V. Extracorporeal Shockwave Therapy Treatment in Upper Limb Diseases: A Systematic Review. J Clin Med. 2020 Feb 6;9(2):453.
  26. Thomas JM, Chang EY, Ha AS, Bartolotta RJ, Bucknor MD, Caracciolo JT, Chen KC, Flug J, Kumaravel M, Raizman NM, Ross AB, Silvis ML, Surasi DS, Beaman FD. ACR Appropriateness Criteria® Chronic Elbow Pain. J Am Coll Radiol. 2022 Nov;19(11S):S256-S265.
  27. Vinod AV, Ross G. An effective approach to diagnosis and surgical repair of refractory medial epicondylitis. J Shoulder Elbow Surg. 2015 Aug;24(8):1172-7.

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