Golfer’s Elbow/Common Flexor Tendinopathy
1. Introduction
Medial tendinopathy of the elbow is also known as ‘golfer’s elbow’ and typically presents with medial elbow pain (pain on the inside of the elbow). It is named due to its association with those who take part in sports such as golf, although in reality, 95% of cases do not result from playing golf (1).
For a long time, we referred to tendinopathies as ‘tendinitis’. This was because we believed that it was primarily an inflammatory condition. This led to treatments such as steroid injections and strong anti-inflammatory medication (such as Diclofenac or Naproxen). However, our understanding of tendon-related pain has improved and we now know that tendon degeneration, as opposed to inflammation, is the primary driver in most tendinopathies.
Our knowledge of treatments such as steroid injections has improved and should only be considered as a last resort, if appropriate, and progressive conservative management has failed. Even if conservative management does not achieve a 100% improvement in symptoms, careful consideration for steroid injection is heavily encouraged as in some cases they appear to cause more harm than good (1).
Our understanding of the best way to manage tendon problems is continually developing and a rehabilitation approach that involves progressive loading is now agreed to be the best approach initially.
Frequently Asked Questions
- Often mistaken for tennis elbow, golfer’s elbow (also known as medial elbow tendinopathy) is an overuse injury that causes pain at the inside of the elbow.
- It is estimated to affect between 1%-3% of the population (1).
- Golfer’s elbow is a common cause of medial elbow pain.
- No.
- With the right rehabilitation approach, golfer’s elbow generally recovers well.
Golfer’s elbow is not linked to other serious pathology.
- Typically, those aged between 40 and 60 (1).
- Repetitive actions involving wrist flexion (bending the wrist with the palm down and fingers facing the floor).
- Men and women are affected equally (1).
- Pain and tenderness – usually felt on the inner side of your elbow. The pain sometimes extends along the inner side of your forearm.
- Increased pain with movement, e.g. gripping & lifting.
- Stiffness – your elbow may feel stiff.
- Weakness – you may have weakness in your hand and wrist.
- Numbness or tingling – these sensations might radiate into one or more fingers, usually the ring and little fingers (1).
- Modify or avoid activities that cause your pain.
- Progressive and appropriate loading of the tendon has been shown to be one of the most effective treatments.
- Advice from a qualified physiotherapist will be helpful in most cases.
- This will depend upon a number of factors including, but not limited to, co-morbidities, stage of injury, adherence to rehabilitation, etc.
- Golfer’s elbow heals well with conservative treatment and exercises when followed correctly.
- It usually takes around 3-6 months to attain complete recovery from golfer’s elbow.
We recommend consulting a musculoskeletal physiotherapist to ensure exercises are best suited to your recovery. If you are carrying out an exercise regime without consulting a healthcare professional, you do so at your own risk.
2. Signs and Symptoms
- Pain localised to the medial (inner) aspect of the elbow.
- Pain can radiate down into the arm from the inside of the elbow.
- Weakness in the hand or wrist.
- Numbness and tingling in the ring and little fingers.
- Pain when gripping or twisting things.
- Pain that is stereotypically produced with activities that require repeated utilisation of the tendon such as throwing, racket sports or weight training.
- Dose-dependent: pain after excessively loading the tendon after exposing it to unaccustomed tensile forces or by repetitive movements.
3. Causes
Symptoms usually develop alongside an increase in load or activity and therefore are most prevalent in people who perform a repetitive job or certain sports. Energy storage and release (like a spring mechanism) from tendons is important as it plays an important role in energy consumption used throughout human movement. Repetition of this spring-like activity over a single exercise session, or with insufficient rest to enable repair and remodelling between sessions, can induce a change in the tendon’s mechanical properties, which is a risk factor for developing symptoms. A staged process of pathologic change in the tendon can result in structural breakdown and gradual worsening of symptoms if the issue is not addressed (3).
4. Risk Factors
This is not an exhaustive list. These factors could increase the likelihood of someone developing golfer’s elbow. It does not mean everyone with these risk factors will develop symptoms.
- Sudden changes in load or activity such as a weekend doing the garden or DIY.
- Ergonomics – long periods of manual or computer work without adequate periods of rest.
- Age – The risk of tendon pain increases as we get older. There is no definitive age range although age generally results in tendon degeneration (1).
- Other medical conditions such as diabetes, high cholesterol or smoking can make tendons more vulnerable to load.
- Taking certain types of medication can lead to the development of tendon pain.
5. Prevalence
In the general population golfer’s elbow affects less than 1%-3% of people. Golfer’s elbow may be seen in any age group of hobbies, jobs or sports activities lead to overuse injuries. Those who are heavily involved in sport, particularly racquet sports (tennis, badminton or squash), or sports that involve throwing (javelin or discus) are more likely to develop symptoms.
6. Assessment & Diagnosis
Musculoskeletal physiotherapists and other appropriately qualified healthcare professionals can provide you with a diagnosis by obtaining a detailed history of your symptoms. A series of physical tests might be performed as part of your assessment to rule out other potentially involved structures and gain a greater understanding of your physical abilities to help facilitate an accurate working diagnosis.
Your treating clinician will want to know how your condition affects you day-to-day so that treatment can be tailored to your needs and personalised goals can be established. Intermittent reassessment will ascertain if you are making progress towards your goals and will allow appropriate adjustments to your treatment to be made. Imaging studies like an MRI or ultrasound scans are usually not required to achieve a working diagnosis, but in unusual presentations, they may be warranted.
7. Self-Management
As part of your treatment, your musculoskeletal physiotherapist will help you understand the condition and what needs to be implemented to effectively manage your golfer’s elbow. This will include activity modification strategies as well as other useful treatments aimed at reducing discomfort. Regular adherence to a condition-specific rehabilitation programme is important in the management of this condition. It should be noted that rehabilitation exercises are not always a quick fix but, if adhered to on a consistent basis (weeks to months), over time they have been shown to yield positive outcomes.
8. Rehabilitation
Research is very clear that modifying the load that goes through the tendon is the key element that stimulates recovery. Recovery can take some time as the speed of tendon regeneration is much slower than other structures in the body.
Below are three rehabilitation programmes created by our specialist physiotherapists targeted at addressing medial elbow tendinopathies. In some instances, a one-to-one assessment is appropriate to individually tailor targeted rehabilitation. However, these programmes provide an excellent starting point as well as clearly highlighting exercise progression.
9. Golfer’s Elbow/Common Flexor Tendinopathy
Rehabilitation Plans
Our team of expert musculoskeletal physiotherapist have created rehabilitation plans to enable people to manage their condition. If you have any questions or concerns about a condition, we recommend you book an consultation with one of our clinicians.
What Is the Pain Scale?
The pain scale or what some physios would call the Visual Analogue Scale (VAS), is a scale that is used to try and understand the level of pain that someone is in. The scale is intended as something that you would rate yourself on a scale of 0-10 with 0 = no pain, 10 = worst pain imaginable. You can learn more about what is pain and the pain scale here.
This programme focuses on maintaining range of movement within the elbow, appropriate loading of the affected tendon and maintenance of lower limb strength and stability. We suggest you carry this out once a day for approximately 2-6 weeks as pain allows. We can work into pain during these exercises but ideally, this should not exceed any more than 3/10 on your perceived pain scale.
- 0
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- 910
This is the next progression. More focus is given to progressive loading of the tendon and upper limb strengthening. As with the early programme, some pain is to be expected but ideally, we do not want this to be any more than 3/10 on your perceived pain scale.
- 0
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- 910
This programme is a further progression with challenging progressive loading of the affected tendon complex. Again, some pain is acceptable but ideally, we do not want it to exceed 3/10 on your perceived pain scale.
- 0
- 1
- 2
- 3
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- 910
10. Return to Sport / Normal life
For patients wanting to achieve a high level of function or return to sport, we would encourage a consultation with a physiotherapist as you will likely require further progression beyond the advanced rehabilitation stage.
As part of a multi-modal treatment approach, your musculoskeletal physiotherapist may also use a variety of other pain-relieving treatments to support symptom relief and recovery. Whilst recovering you might benefit from a further assessment to ensure you are making progress and establish the appropriate progression of treatment. Ongoing support and advice will allow you to self-manage and prevent future reoccurrence.
11. Other Treatment Options
Corticosteroid injections should only be considered as a last resort if appropriate and progressive conservative management has failed. Even if conservative management does not achieve a 100% improvement, careful consideration is heavily encouraged as in some cases they cause more harm than good, including in rare instances tendon rupture.
Surgery should only be the last option if all other treatment attempts have been exhausted.
References
- Rahman Shiri, Eira Viikari-Juntura, Helena Varonen, Markku Heliövaara. (2006) Prevalence and Determinants of Lateral and Medial Epicondylitis: A Population Study. American Journal of Epidemiology. 164, 1065–1074.
- Jørgen R Jepsen, Lise H Laursen, Carl-Göran Hagert, Svend Kreiner & Anders I Larsen. (2006)Diagnostic accuracy of the neurological upper limb examination II: Relation to symptoms of patterns of findings. BMC Neurology.
- Amin, Nirav H. MD; Kumar, Neil S. MD, MBA; Schickendantz, Mark S. MD. (2015) Medial Epicondylitis Evaluation and Management. Journal of the American Academy of Orthopaedic Surgeons: 23, 348-355.
Other Conditions in
Chest / Core
Tennis Elbow/Common Extensor Tendinopathy
A condition that causes pain around the outside of the elbow. It often happens after overuse of the muscles of the forearm.
Benign Joint Hypermobility Syndrome
Common age related changes to the structure of the knee joint which may be associated with pain, stiffness and loss of function.