How Physiotherapists Treat Golfer’s Elbow

Golfer’s elbow, more technically called medial epicondylitis, is a similar type of condition to tennis elbow or lateral epicondylitis, but is less common. Since there is little or no inflammation present in these syndromes, they are known as tendinopathies, where degeneration of the tendon occurs and gives symptoms. Typical aggravating factors are racquet sports, golf and sports which involve throwing, although other sports people may be affected such as weight lifters, archers and cricket bowlers.

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.

High stresses occur in the cocking phase of a throw and during the subsequent acceleration, and in the golf swing from high backswing down to near the ball strike. Golfers are more likely to have their dominant hand affected and tennis players who use heavy topspin in their forehands are also more at risk.

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.

Typical symptoms are an ache or pain over the front of the inner elbow which is worsened by repeated wrist bending and improved by rest. Hand, forearm, elbow and shoulder pain may be reported, with grip weakness in the hand. If the ulnar nerve is involved this can also contribute to the weakness and give pins and needles in the forearm. The physio palpates the muscles and their tendinous insertions, the elbow joints and the groove behind the elbow where the ulnar nerve lies. To exclude other significant diagnoses the physiotherapist will perform a neurological examination.

The main treatment of golfer’s elbow is conservative, including anti-inflammatories, wrist and forearm splinting, corticosteroid injection and physiotherapy. Modifying the provoking activity is a first line of management, making patient education about the condition and the eliciting factors vital. An example is modifying the golf swing mechanics to avoid setting the problem off continually. The patient is taught to avoid aggravating positions and activities, such as leaning on the elbow if there is nerve involvement.

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.

Corticosteroid injections are commonly used for treatment of longer term medial epicondylitis but are more useful early on in the management of golfer’s elbow to relieve pain. Laser and shockwave therapy have no good evidence for usefulness. Surgery is only considered once conservative physiotherapy has failed. Surgery is used to debride the abnormal tissue from the affected area and in the cases of nerve involvement to move the ulnar nerve from its groove round to the front of the elbow.

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.