Golfer’s Elbow: Causes, Symptoms, and Treatment

Patients suffering from a golfer’s elbow have pain on the inside of the elbow, in the area of the bony protrusion where the tendons are attached. Therefore, a golfer’s elbow is an inflammation of the tendon attachment (= attachment tendinosis) of the muscles of the forearm flexor. The cause of the chronic inflammation of the epicondyles medialis humeri is unclear. Still, it is assumed that overstrain at work or in sports (e.g., golf) has a mechanical triggering effect. This also explains the origin of the term “golf elbow.”

Other tendons can also be affected by pain in the elbow.

Quite often, patients complain of pain radiating into the forearm or upper arm, so that the entire arm may hurt. Usually, there is a local stabbing pressure pain at the bone base of the affected muscles, as well as inflammatory pain on the inside of the elbow (inflammation of the elbow), which is caused by fist closure and flexion, especially against resistance.

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Symptoms of golfer’s elbow

If the patient has a golfer’s arm, he feels a pressure pain on the inside of the elbow, where swelling may also occur.

The closing of the fist or the bending of the hand and forearm, especially against resistance, is painful so that the patient is increasingly restricted in everyday life.

The pain often radiates into the upper arm as well as into the forearm and the hand, so that the patient describes a pain in the whole arm and there is a reduction in strength of the hand and finger muscles so that the patient can no longer grip properly.

Pain

The complaints of the golfer’s elbow are triggered by pain-inducing substances, for example, the so-called substance P or prostaglandin E2, which are released in the course of changes in the muscle attachments as a result of incorrect or excessive strain and stimulate nerves, which then transmit this signal to the brain as a pain stimulus.

The typical complaints of the golfer’s elbow can be described as stabbing pain on the inside of the elbow, which often radiates to the flexion side of the forearm. The complaints often occur with increasing intensity when the muscles are strained, for example, when forming a fist or when grasping an object with the arm stretched. The flexion of the wrist and fingers is also affected, especially when the movement is against resistance.

Due to the load-dependent complaints, there is often a massive restriction in everyday life, as even simple tasks, such as writing or lifting objects, can become a problem due to pain. Many patients also report a pressure pain on the inside of the elbow. This also extends along the flexor muscles of the forearm. Increasingly, it is not only an active movement that causes pain, but also maximum passive stretching. If further incorrect strain is applied or no therapy is carried out, the pain can also occur at rest.

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Duration

After the diagnosis of a golfer’s elbow, the painful arm is often immobilized for up to two weeks, for example, with the help of a splint. After this period, the immobilization should be revoked, as otherwise, the muscles may be shortened, and the joint may stiffen.

Treatment can be lengthy but is necessary to prevent chronic progression. If the golfer’s elbow has been treated by surgery, the arm is immobilized with a splint for 10 to 14 days, depending on the healing process. Afterward, the movement is optimized again through various physiotherapeutic exercises. The duration varies from person to person and depends, among other things, on the patient’s cooperation, but also on how the patient’s body can cope with the strain. Incapacity to work depends on the professional activity and usually lasts between two and eight weeks.

Causes of golfer’s elbow

The term “golfer’s elbow” does not mean that only golfers or athletes suffer from this disease. The “golfer’s elbow” occurs relatively rarely in athletes, usually as a result of a mislearned technique.

Since the golfer’s elbow is caused by chronic mechanical overstrain, craftsmen, mechanics, road and construction workers or secretaries are particularly affected.

In the course of the disease, painful wear and tear occurs in the insertion area of the flexor muscles of the wrist. The golfer’s elbow also frequently occurs in older patients. Examinations show here under certain circumstances strongly pronounced degenerative (arthritic) changes in the elbow joint.

The forearm flexor muscles are suspended at the end of the humerus on the inside. With it, the person can bend the elbow as well as the wrist and fingers.

The muscle attachment tendons of this muscle group are thus stressed during many movements.

The causes of a golfer’s arm are usually due to overloading or incorrect loading of the affected arm. There can be many reasons for this; a golfer’s arm does not only occur after playing golf but can also be triggered by other activities. Typical triggers are heavy loads on only one arm, for example, when climbing, especially if the movements are not technically appropriately executed.

In everyday life, a golfer’s arm can also occur, often triggered by hours of operating a computer mouse. Why these strains lead to an inflammatory process in the muscle attachments is not fully understood, but the mechanical irritation of the tissue plays a significant role.

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Diagnosis of a golfer’s elbow

The diagnosis can usually be made based on a medical history and a simple physical examination.

The doctor will trigger typical pain points by applying pressure. It is important to make sure that there is no injury to the bones or elbow joint causing similar symptoms. Additional tests will also be carried out, such as the provocation test:

With the elbow joint stretched, the wrist is extended, and the arm is supported on a table with the ball of the hand. In the case of the golfer’s elbow, the pain at the inner elbow increases.

During this test, the flexor muscles on the forearm are subjected to maximum stress. The tendons at the inner elbow are subjected to increased tension. The diseased tendons react to this with increased pain. To rule out other diseases, an X-ray can be taken to see whether the pain is caused by, for example, old fracture consequences.

Among the occupational groups at risk are those who have to use the forearm flexors intensively. These are especially craftsmen, mechanics, or construction workers.

Because of the severe pain of the golfer’s elbow, which is becoming more and more frequent when performing everyday activities and is sometimes so severe that even lifting light objects becomes a torture, the patient visits a doctor. Patients often also complain about the pain radiating into the muscles of the forearm.

During the clinical examination of the golfer’s elbow, a severe pain of pressure and touch on the tendon attachments concerned is to be induced. Due to the pain, there is a restriction of movement in the elbow joint, but this is relatively rarely caused by degenerative/wear-related changes.

As part of the medical examination, the doctor carries out so-called resistance tests on the golfer’s elbow. The patient has to make a fist and push it up or down against force. If the patient has a tennis elbow or golfer’s elbow, this test increases the pain in the elbow joint. Often, the entire forearm musculature is very tense, and, under certain circumstances, slight sensory disturbances can occur, which can be felt, for example, by a tingling sensation. They are usually not caused by a cervical syndrome (cervical spine syndrome) or local nerve damage.

When pressure is applied to the original zones of the finger, a severe, stabbing pain occurs. Due to the pain of the patient, there is also always a limitation of movement of the elbow joint. However, this is only in sporadic cases due to degenerative changes and is rather painful.

During an ultrasound examination, the physician can detect swelling in the area of the tendon attachment. In contrast, X-ray examinations of the elbow joint only very rarely and usually in more advanced stages reveal pathological changes. In cases in which the golfer’s elbow has already reached a chronic stage, calcification foci in the tendon attachment area or small periosteal irregularities (= periosteum irregularities), as well as bone excrescences, may be visible on the X-ray image.

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Golfer’s elbow and tennis elbow tests

Epicondylitis humeri radialis (tennis elbow)

Pain in the area of the outer elbow:

  • Rotation of the forearm
  • Wrist extension against resistance
  • Extension of the middle finger against resistance
  • Extension of the elbow and passive bending of the hand

Epicondylitis humeri ulnaris (golfer’s elbow)

Pain in the area of the inner elbow:

  • Bending of the wrist.
  • Rotation of the forearm against resistance
  • Lifting heavy things

Therapy of golfer’s elbow

In some cases, doctors recommend surgery.

If there are complaints in the form of a golfer’s arm, it is advisable to spare the affected arm. This will prevent the inflammation process from progressing and the symptoms from worsening.

The therapy of the golfer’s arm is usually conservative. Only in rare cases, an operation is performed.

There are numerous possibilities and variants of conservative therapy, some of which are presented below.

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Physical measures

As with other inflammations in the body, it is helpful if the golfer’s arm is cooled. This stops inflammatory processes and relieves pain. Advantageously, the cooling of the painful areas can also be carried out by patients themselves. Also, many physiotherapists use electrostimulation when treating the golfer’s arm.

The technique used is called TENS, which stands for “transcutaneous electrical nerve stimulation.” Here, electrical impulses are emitted onto the skin via electrodes. With the help of this procedure, the nerve fibers that transmit the pain are to be reached. The goal is that less pain information is transmitted to the brain. The therapy is not painful so that the patient only feels a tingling sensation on the skin.

An advantage of this procedure is that patients can also carry out applications independently at home using a rented or purchased device. Another widely used therapy is shock wave therapy. Here, the aim is to stimulate the tissue with the help of shocks, thereby increasing blood circulation and regenerating the tissue, which should ultimately result in a cure.

In the meantime, this form of therapy is mentioned in the therapy guidelines. However, there are still many who are skeptical about this type of treatment. Unfortunately, the statutory health insurance companies steadfastly refuse to cover this effective therapy.

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Surgery of golfer’s elbow

If, after six months of treatment, the symptoms do not improve or even worsen, surgical therapy should be considered together with the treating physician.

Unless there are circumstances that speak against it, such as a lack of care at home after the operation or complications associated with anesthesia in previous operations, it is usually possible to operate the golf elbow on an outpatient basis.

Furthermore, the operation is often minimally invasive, which means that the surgeon inserts his devices through small skin incisions, and a complete opening of the joint is not necessary. However, it is essential to note that the ulnar nerve runs close to the affected joint, and special care is required during surgery.

Some surgeons, therefore, still prefer a conventional operation with the opening of the joint. Which procedure is used in each case must be decided with the treating physician. The anesthesia can be either a regional anesthesia into a vein, a plexus anesthesia, i.e., anesthesia of all nerves in the armpit and thus of the entire arm, or in special cases a general anesthesia.

When operating, a distinction can be made between two standard procedures.

The Hohmann surgical technique involves cutting through the origin of the muscles that start at the elbow and cause pain. To do this, a small incision is first made in the elbow with a scalpel, and the muscles underneath with their attachments are exposed. Since the skin is very elastic, the incision does not have to be large. The surgeon can simply push the skin a little to the side to see all the important muscles. This allows the surgeon to see the muscle attachments that are under tension and thus responsible for the pain in the elbow. Now, these tense fiber strands are cut through, and in this way, the arm is relieved. Those muscle attachments that are loose and relaxed remain untouched and preserved, as they have nothing to do with the origin of the pain. Once all the necessary attachments have been severed, the surgeon checks the free mobility of the arm in the operating theatre and under anesthetic. Also, the surgeon tests whether a firm handshake by a third person reveals a depression near the elbow. This is usually the case. If the surgeon is satisfied with these two tests, the wound is closed again.

In the second standard technique, according to Wilhelm, the smallest nerves responsible for supplying the elbow and thus for transmitting the pain to the golfer’s elbow are cut through and sclerosed. This process is also called denervation. Mostly a combination of both techniques is used. After the operation on the golfer’s elbow, the arm is immobilized with an upper arm cast for about two weeks. After the removal of splints and stitches, movement exercises should be performed if there is no pain. In some cases, physiotherapy is also useful. The costs of such an operation are currently not covered by many statutory health insurance companies, so you should enquire with the respective health insurance company in a good time.

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Homeopathy

In addition to medicinal, conservative, and surgical treatments, the use of homeopathic remedies is another option.

At the beginning of a homeopathic treatment, there is usually a detailed anamnesis interview. The focus is not only on the actual complaints, the golfer’s elbow but also on the whole person and his current condition. In this way, the homeopath tries to get an impression of the overall situation and to distinguish symptoms caused by the golfer’s elbow from symptoms of other origins.

Based on this conversation, the homeopath can then decide which remedy should be used in the case of the individual patient. It is, therefore, difficult to give a general indication of useful substances.

Bandages and braces for golfer’s elbow

Sports braces can immobilize the joint for some time and promise relief. Special elbow brace ensures a gentle position, but at the same time allow partial use of the joint.

Tape treatment

Kinesiotaping involves applying an elastic adhesive bandage directly to the skin. This has a regulating effect on the muscular balance in the elbow joint. Kinesio tapes are used both therapeutically and preventively. The effect of Kinesiotapes is indirect through the stimulation of skin receptors on the musculature. Depending on the desired effect, various application techniques are available. The application technique is determined by consultation with a physiotherapist and a doctor. However, this effect has not been scientifically proven.

Before applying the tapes, the skin must be cleaned so that it is free of oils, creams, and hair. This increases the durability of the tapes on the skin. The tape should be left on for about one week, whereby the main effect is expected in the first 3-5 days after application. Bathing, swimming, and sports are also possible after application. Itching may be felt under the tape; if this occurs, it should be removed.

Medication

Creams or gels with anti-inflammatory agents like Diclofenac are suitable for superficial application.

A stronger effect is achieved if pain and anti-inflammatory drugs in the form of tablets are taken for some time.

These are, for example, ibuprofen or Diclofenac. These active ingredients can irritate the stomach lining, which is why other medicines, e.g., pantoprazole, may have to be taken to protect the stomach.

Injections

There is also the possibility of injecting painkillers at the affected elbow to relieve the pain. Cortisone is also suitable for injection and inhibits inflammation in the golfer’s arm. However, caution is advised, as the inflamed area in the golfer’s arm is very close to the ulnar nerve. During the injection, the doctor injects the selected substance into the irritated tissue. Still, he must not hit the nerve, as this causes a sudden stabbing pain on the one hand, and the nerve may be damaged by cortisone on the other.

Physiotherapy

If the inflammation in the affected arm is acute and very painful, physiotherapeutic measures should be avoided at first.

It is advisable to wait for initial pain relief and containment of the inflammation while taking it easy and using other treatment concepts.

If only mild symptoms are still present, physiotherapy can be started.

It has been shown that especially stretching the surrounding muscles is very promising and often exceeds the benefit of other therapies. Suitable stretching exercises are presented under the heading Exercises.

Surgical approaches

The decision to have surgery on the golfer’s arm should be carefully considered. It is recommended that conservative therapies are initially applied for six to twelve months, as surgery cannot guarantee a cure. As a rule, surgery on the golfer’s arm can be performed on an outpatient basis, i.e., hospital admission is not necessary. The operation is usually not performed under general anesthesia, but with plexus anesthesia. This involves the use of local anesthetics to numb the nerves of the arm so that the patient feels no pain.

Most surgeons operate on the golfer’s arm by making a small incision over the affected tendon attachment, then severing it and removing any calcifications so that the tissue is not further irritated. This technique, which is called Hohmann’s operation, can be combined with the obliteration of small nerve endings in the elbow joint so that no more pain can be transmitted. This procedure is called the operation, according to Wilhelm.

In comparison to tennis elbow, there is a higher risk of damage to the ulnar nerve when operating on golfer’s elbow because it is located near the operating field.

To minimize this risk, the surgeon must know exactly where the nerve runs, which is why he or she is first visited after the skin incision before the actual operation begins.

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Stretching

Stretching exercises are a good way of preventing pain, as is the case with the golfer’s elbow, or of improving already existing pain. These exercises relieve the tendon attachments and thus avoid a state of tension of the muscle attachments that leads to pain. It should be noted, however, that the exercises should ideally be performed in consultation with a doctor. Furthermore, it is advisable to consult a doctor if the pain does not improve or even gets worse.

The tendons of the wrist flexors, i.e., the tendons that attach to the inside of the elbow, are stretched, for example, by stretching the arm where the golfer’s elbow has occurred horizontally forwards with the palm facing upwards. Then the hand is bent downwards in the wrist, i.e., towards the ground. On the other hand, grasp the fingers and help to move down until you feel a stretching at the inner elbow. The same effect can be achieved by placing the flat hand on a tabletop with the fingers pointing towards your body. In both exercises, the affected arm must remain stretched the whole time.

Prognosis

The prognosis can be described as good, since most patients with disease of the golfer’s elbow can be cured conservatively, i.e., without surgery. However, it is possible that the disease occurs over a long period and under certain circumstances can only be cured with surgery. In rare cases, even an operation cannot provide lasting relief from the pain.

The golfer’s elbow/golf elbow also frequently occurs with tennis elbow.

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