Medial Epicondylitis / Golfer’s Elbow

“Hey, doc! My elbow hurts.” – Unfortunately, this is not an uncommon thing we hear from people on the golf course, at the gym, or in the clinic.

Medial epicondylitis, also known as golfer’s elbow, climber’s elbow, common flexor tendinosis, and others, affects people from a variety of occupations and activities, It is certainly not limited to the golfer or rock climber.

It constitutes 10-20% of all cases of epicondylitis and typically develops in the dominant arm [Baumgard]. It most commonly occurs due to chronic repetitive activity. In this post, we’ll discuss the symptoms, diagnosis, and treatment of a golfer’s elbow.

What Is Golfer’s Elbow?

And so golfer’s elbow can also develop when there is laxity or instability in the ulnar collateral ligament and pain or soreness on the inside of the elbow. The common flexor tendon and UCL together stabilize the flexion motion at the elbow.

The bony bump you feel there is the medial epicondyle of the humerus (upper arm bone). The five forearm muscles that attach here are involved in flexing or rotating the forearm and wrist.

Repetitive motion with extreme eccentric force on the muscles and ligament can cause the degeneration and formation of granulation tissue. This is called tendinosis and can cause pain. The pain can get worse when you throw a ball, grip a dumbbell, turn a screwdriver, and do other movements that involve the fingers, hand, wrist, and/or elbow.

What Causes The Pain?

Small tears develop in the tendons that attach muscles to bone. These small injuries can occur over time with normal day-to-day activities, not just with a traumatic event. Most of the time, our body does a good job of repairing them without issue.

As we age, those repair mechanisms do not work quite as well, so small tendon tears may not heal back to 100%. Often, other issues can cause excess muscle/tendon load or improper firing of the muscles.

The ulnar collateral ligament is something all too familiar with baseball players. It is triangular shaped and acts like pieces of duct tape, stabilizing the humerus and ulna, the two bones that make up the inner elbow joint, together.

This ligament can get loose, acting like a rubber band instead of a piece of duct tape. This causes the flexor tendons to work harder to provide stability to the elbow joint, which can result in injury to the tendon.

The nerve supply to the flexor muscles originates from the lower half of the cervical spine. If any of these nerves are irritated, it can result in disrupted communication to the muscles, causing them to improperly activate. Think of it as the circuit breaker in your home.

If the problem is at the breaker box, it doesn’t matter how many times you change the lightbulb until you fix the source. This is why the physicians at Centeno-Schultz Clinic may ask about your neck when you’re having elbow pain.

What Makes It Different From Tennis Elbow

Tennis elbow is similar, however, it refers to the outside of the elbow, at the lateral epicondyle. Pain typically can be reproduced if you make a fist and bend your wrist backward into an extension. It is actually much more common than a golfer’s elbow but is generally treated in a similar fashion.

Symptoms of Medial Epicondylitis

Individuals with medial epicondylitis have many symptoms that are usually relieved with rest and stopping any flexion activity. The following are the symptoms usually seen with a golfer’s elbow. 

• Pain and tenderness: Pain at the ulnar side is one of the first symptoms of a golfer’s elbow. Individuals have an aching pain on the medial or ulnar side of the elbow. This pain can radiate from the epicondyle down into the forearm and wrist.
  
  It is often gradual and progresses over time. It can occur acutely due to injury to the elbow as well. Any forearm motion like gripping, or throwing exacerbates the pain. In athletes, actions such as overhead throwing, forearm tennis stroke, or swinging a golf club can worsen the pain.
  
  On touching the elbow, there is usually tenderness at the site of the medial epicondyle.
• Stiffness: There may be some stiffness due to the replacement with fibrous tissue or the presence of calcification
• Weakness: In addition to the pain, there may be some weakness of the flexor muscles due to the replacement of collagen with scar tissue.
• Numbness or tingling: Along the distribution of the ulnar nerve there may be some tingling and numbness. The ulnar nerve passes under the medial epicondyle of the elbow and can be affected by the tendinopathy or inflammation here.

Arm Pain at Night

Arm pain at night can be miserable.  The pain can interrupt your sleep and erode your quality of life. Irritability becomes increasingly more common.  What are the causes?  When should I worry about it?  What are the treatment options for arm pain at night? The neck is composed of 7 boney building blocks numbered 1- 7. Sandwiched between the bones is a disc that functions as an important shock absorber. The cervical discs are susceptible to injury due to trauma, degeneration, repetitive motion, and surgery. Common disc injuries include disc bulges, and herniations. The injured disc can compress or irritate one or more nerves resulting in arm pain at night. It can…

Read More About Arm Pain at Night

Arm Throbbing

In many patients, irritated neck nerves don’t present as a symptom in the neck. In fact, sometimes the only symptoms of irritated nerves in the neck occur in the arm muscles, as either tightness, throbbing, or both. While the arm throbbing might be frustrating as it’s happening, you might not think a whole lot about it, especially if it only happens on occasion. However, ignoring it is not a good idea since it is often a warning signal of a bigger problem in the neck. These body connections occur all the way back to when we were a fetus, like the neck, shoulder, and arm.

Read More About Arm Throbbing

Hands Stiff in the Morning

Hand stiffness can make simple tasks overwhelming. Why are my hands stiff in the morning? What are the treatment options for hand stiff in the morning? Are there new, natural treatment options to treat hands that are stiff in the morning? Our hands are central to virtually everything we do. Stiffness can compromise function and cause pain. What are the causes of hand stiffness in the morning? There are many which include: excessive daily wear and tear, medications that can cause hand swelling and stiffness. Common examples include hormones, calcium channel blockers for high blood pressure, steroids, anti-depressants, and NSAIDs, Diets high in salt, alcohol, and trauma.

Read More About Hands Stiff in the Morning

Left Arm Numbness

Treatment depends upon the underlying cause of the arm numbness. Left-arm numbness is a warning sign that requires attention. As noted above unexplained numbness requires immediate attention. At the Centeno-Schultz Clinic, we are experts in the treatment of left-arm numbness due to cervical nerve irritation, cervical stenosis, thoracic outlet syndrome, and peripheral nerve injuries. When appropriate first-line treatment should involve conservative care including physical therapy and stretching. Steroid injections should be avoided as they are toxic to orthopedic tissue and can accelerate damage. Surgery for Cervical Stenosis and Thoracic…

Read More About Left Arm Numbness

Pain on Outside of Elbow

Pain on the outside of the elbow which is referred to as lateral epicondylitis can be disabling. Typically seen in 30-60 year olds, patients complain of point tenderness over the outside aspect of the elbow ( lateral epicondyle) aggravated by gripping and activities that extend the wrist. The pain is thought to arise from degenerative changes in the muscles that attach to lateral epicondyle called the extensor muscles.

Read More About Pain on Outside of Elbow

Can You Get Medial Epicondylitis Even If You’re Not A Golfer?

It’s not necessary to be a golfer to develop medial epicondylitis. People with the following risk factors can also experience golfer’s elbow.

Repetitive Motions That Cause Elbow Pain

Any repetitive flexor motion of the elbow can cause medial epicondylitis. The chronic repetitive concentric or eccentric loading of the flexor musculature can cause recurrent microtears within the tendon. The recurrent micro tears cause the body to re-organize the collagen and lay down fibrous tissue instead. Calcium may be deposited in some cases.

This leads to a weakened tendon that is more fragile but thicker and more prone to further tears. These tears cause pain and any flexor activity will worsen this pain. Some repetitive motions that cause this tendinosis are listed below.

• Carrying heavy luggage
• Operating a chainsaw (or other power tools)
• Using an ax to chop wood
• Using hand tools frequently

Non-Golf Professions With Risk Factors

In other professions where wrist flexion and forearm pronation occur on a regular basis, golfer’s elbow is very common. These professions are the following:

• Plumbers
• Butchers
• Cooks
• Regular computer users
• Construction workers
• Painters
• Assembly line workers

Diagnosing Golfer’s Elbow

A trained musculoskeletal physician is usually able to diagnose a golfer’s elbow by talking with you about your history and performing a physical exam. The doctor may perform a golfer’s elbow test which has an active and passive component. The patient is asked to resist wrist flexion with the arm extended and supinated.

The passive component includes extending the wrist with the elbow extended. If there is any pain while doing any of these components, the test is considered positive. A diagnostic ultrasound imaging may be done to assess for any tendon abnormalities such as swelling or tears.

If there is chronic degeneration, this can be picked up on ultrasound. An X-ray may be done to rule out a hairline fracture but in a golfer’s elbow is usually normal. 

As mentioned above, other areas of the body may be examined to see if there are any other factors leading to your elbow pain.

At times, imaging such as an MRI, bone scan, or CT may be done just to rule out other causes of medial elbow pain like a muscle tear or strain. Nerve conduction tests and electromyograms are usually done if there is suspected ulnar nerve involvement. 

Home Treatment Options

The first line of treatment for a golfer’s elbow is home therapy. This can be done easily for individuals who are experiencing medial elbow pain initially. Some of these therapies include the following:

• Stretching: Stretching exercises stretch the flexor muscles in the forearm. They can be done actively or passively. In active stretching, the individual stretches the muscles themself. In active stretching, a trainer or partner can help them do the stretch.
  
  One such stretch is where the person stretches the affected arm in front with the palm facing upwards. Relax the wrist. Using the other hand pull the affected hand back towards the body. Hold for about 30 seconds and then repeat. 
• Rest: One of the best ways to treat a golfer’s elbow is to completely stop the aggravating activity. Discontinue the golf swing, tennis forehand, lifting luggage, using tools, or whatever flexor activity that causes the pain.
• Counterforce Bracing: This is an elbow compression strap. It is wrapped around the forearm slightly below the elbow. It applies some pressure on the muscle and eases the pain.
• Naturopathic Anti-Inflammatory (e.g., turmeric, bromelain): Turmeric contains cucurmin that has been shown to have antioxidant, anti-inflammatory, and immunomodulatory properties that can significantly reduce golfer’s elbow pain (1).
  
  Studies show that bromelain has reduced pain and improves wound healing which could be used in patients with golfer’s elbow (2).

Medical Treatment Options

The traditional medical treatment options for golfer’s elbow include anti-inflammatory medications, cortisone injections, and surgery. However, these therapies are falling out of favor due to the many complications and long-term effects on the bone and the joint. They are explained in detail below.

Cortisone Injections

High-dose corticosteroid injections are unfortunately common in the traditional orthopedic and sports medicine world. There are many studies out there that show the negative effects of these (3).

They cause osteoporosis and further weaken the bone. Although they may mask the pain for a short period, they are doing nothing to heal the tissue and can actually cause MORE injury to tendon cells and cartilage.

Surgery

Surgery for this issue should be a LAST resort. Surgical procedures involve the release of the common flexor tendon at the epicondyle. Any pathologic tissue is debrided during the surgery.

Another surgical option is the mini-open muscle resection. Here the degenerative tissue of the flexor carpi radialis is removed. Fascial elevation and tendon origin resection (FETOR) is another surgery that can be done for a golfer’s elbow.

At Centeno Schultz Clinic (CSC), surgery is not considered until all other options have been exhausted. Even the most careful surgeon is still using a knife to cut into you, which can create scar tissue and potentially other issues down the road.

Non-Surgical Options

At CSC, there are many non-surgical options that are used to treat a golfer’s elbow. These include physical therapy, prolotherapy, platelet-rich plasma, and bone marrow concentrate. They are explained in detail below.

Physical Therapy

Physical therapy is a very good way of stretching and strengthening the muscles of the forearm. Strengthening exercises are usually eccentric exercises in which the muscles lengthen. These exercises improve the flexibility of the muscles. 

An example is picking up a weight in your hand. The weight should be about 30% of the maximum that you can tolerate. Pull it towards you. Lower it slowly. Working against gravity will strengthen the forearm muscles and ease the pain.

When deciding on a PT, consider working with a Titleist Performance Institute (TPI) certified therapist. They have specific certifications for golf athletes and can help recommend a treatment plan tailored to you.

Prolotherapy

Prolotherapy is the utilization of hyperosmolar dextrose to act as an irritant, stimulating your natural healing response. This results in the release of growth factors and increases collagen production in the tendon. This will increase the tensile strength of the flexor tendon and the ulnar ligament.

Platelet-Rich Plasma

Platelet-rich plasma (PRP) injections are a step up from prolotherapy, putting platelets (which contain growth factors) directly at the site of injury. 

A newer study from Bohlen et al. compared PRP treatment of a golfer’s elbow to surgery. They found that overall treatment outcomes were the same, but those who had PRP injections had full range of motion and were pain-free almost 2 months earlier than the surgery patients.

Bone Marrow Concentrate

Bone marrow concentrate (BMC) is usually reserved as a treatment option for large tendon tears, severe arthritis, or injuries that do not respond adequately to prolotherapy or PRP injections.

The bone marrow usually is taken from the back of your pelvis and concentrated to put all the healing cells into a small volume. Then under ultrasound or x-ray guidance, the BMC is injected into the tissues that need help with healing.

Nerve Hydrodissection

Nerve Hydrodissection is a medical procedure that aims to free up scar tissue or adhesions on a given peripheral nerve. The procedure utilizes ultrasound guidance to visualize both the needle and the targeted nerve. Medication is then injected through the needle to free up the scar tissue. Nerve Hydrodissection is a minimally invasive treatment option for many peripheral nerves that are compressed or entrapped by scar tissue.Pain is an uncomfortable and at times painful sensation. It varies significantly from patient to patient. There are many different types of pain which include inflammatory, nociceptive, and neuropathic. Neuropathic pain is pain that arises from nerve compression or injury.

Read More About Nerve Hydrodissection

Prolotherapy Injections

It has been successful in the treatment of many disorders including neck, shoulder, knee, and ankle pain. Dr. Centeno recently published an article in The Journal of Prolotherapy in which he discusses the use of x-ray guidance with prolotherapy. This ensures that the injection is in the correct place to maximize clinical results. Dr. Centeno discusses the use of prolotherapy for the treatment of neck, knee, sacroiliac joint, ankle, ischial tuberosity, and shoulder pain. At the Centeno-Schultz Clinic x-ray guided prolotherapy is just one of the therapies utilized in the successful treatment of pain. Regenerative injection therapy (RIT) or prolotherapy…

Read More About Prolotherapy Injections

PRP Injections

PRP is short for platelet-rich plasma, and it is autologous blood with concentrations of platelets above baseline values. The potential benefit of platelet-rich plasma has received considerable interest due to the appeal of a simple, safe, and minimally invasive method of applying growth factors. PRP treatments are a form of regenerative medicine that utilizes the blood healing factors to help the body repair itself by means of injecting PRP into the damaged tissue. In regenerative orthopedics, it is typically used for the treatment of muscle strains, tears, ligament and tendon tears, minor arthritis, and joint instability. There have been more than 30 randomized controlled trials of PRP…

Read More About PRP Injections

Tenex Procedure

The Tenex Health TX® System is a minimally-invasive, percutaneous procedure using ultrasonic energy to treat pain-generating soft and hard tissue conditions. This treatment is clinically proven to remove tendon pain for over 85% of patients1,2,3,4,5. If conservative approaches such as physical therapy, cortisone injections, medication, and downtime do not provide relief, Tenex may be your next option.Using this technique, we help patients restore musculoskeletal function, may provide quick pain relief, and avoid invasive surgery and dangerous drugs. Tenex may also be effective if you have had a failed surgical procedure. Your doctor will use image-guidance to identify and target the…

Read More About Tenex Procedure

Preventing Golfer’s Elbow

It is possible to prevent a golfer’s elbow by doing the following:

• Pay attention to the wrist and forearm during warmups: Warm-up exercises can drive more blood and oxygen to the flexor muscles. This will allow more nutrients to the muscle during contraction and also improve healing when there are micro tears.
• Adjust your equipment and technique: Whether is your tool or a golf club, ensure there is a larger grip size on the racquet. Improve the forehand techniques so that there is less stress on the flexor-pronator muscle. 
• Add breaks to rest your arm or do stretching exercises: If there is pain, stop doing the action. Continuing with the flexor activity will worsen the microtears. Perform stretching exercises when there is pain to stretch out the muscle and improve healing.
• Wear a wrist brace for additional support: This counterforce brace is a band or strap worn on the forearm. It helps to relieve the strain on the tendon and must be worn even when you are not using performing the flexion motion.
• Strengthen the forearm muscles: This can be done by squeezing a tennis ball and lifting light weights to make the forearm muscles stronger. This will prevent future tears in the tendon.

Be Free Of Golfer’s Elbow Pain

Golfer’s elbow is a condition of the medial elbow that can take you out of work and the things you enjoy doing in life. However, there are many treatment options for this condition. Golfer’s elbow can be treated without surgery through conservative therapies like prolotherapy, PRP, and bone marrow concentrate.

These therapies may not be offered everywhere. At CSC, our board-certified doctors recommend these approaches before surgery to avoid the complications that come with surgical procedures. Reach out to the Centeno-Schultz Clinic education center to schedule an appointment. 

Rest assured that you will receive a treatment plan for the golfer’s elbow personalized for you, designed to target the cause of injury and boost your body’s ability to heal.

You can free yourself from elbow pain and other golf-related conditions. Browse through our articles on golf injuries and learn more about the available treatment options!

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All Our Doctors Who Treat Golfer’s Elbow

Christopher J. Centeno, MD

Christopher J. Centeno, M.D. is an international expert and specialist in Interventional Orthopedics and the clinical use of bone marrow concentrate in orthopedics. He is board-certified in physical medicine and rehabilitation with a subspecialty of pain medicine through The American Board of Physical Medicine and Rehabilitation. Dr. Centeno is one of the few physicians in the world with extensive experience in the culture expansion of and clinical use of adult bone marrow concentrate to treat orthopedic injuries. His clinic incorporates a variety of revolutionary pain management techniques to bring its broad patient base relief and results. Dr. Centeno treats patients from all over the US who…

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John Schultz, MD

John R. Schultz M.D. is a national expert and specialist in Interventional Orthopedics and the clinical use of bone marrow concentrate for orthopedic injuries. He is board certified in Anesthesiology and Pain Medicine and underwent fellowship training in both. Dr. Schultz has extensive experience with same day as well as culture expanded bone marrow concentrate and sees patients at the CSC Broomfield, Colorado Clinic, as well the Regenexx Clinic in Grand Cayman. Dr. Schultz emphasis is on the evaluation and treatment of thoracic and cervical disc, facet, nerve, and ligament injuries including the non-surgical treatment of Craniocervical instability (CCI). Dr. Schultz trained at George Washington School of…

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John Pitts, M.D.

Dr. Pitts is originally from Chicago, IL but is a medical graduate of Vanderbilt School of Medicine in Nashville, TN. After Vanderbilt, he completed a residency in Physical Medicine and Rehabilitation (PM&R) at Emory University in Atlanta, GA. The focus of PM&R is the restoration of function and quality of life. In residency, he gained much experience in musculoskeletal medicine, rehabilitation, spine, and sports medicine along with some regenerative medicine. He also gained significant experience in fluoroscopically guided spinal procedures and peripheral injections. However, Dr. Pitts wanted to broaden his skills and treatment options beyond the current typical standards of care.

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Jason Markle, D.O.

Post-residency, Dr. Markle was selected to the Interventional Orthopedic Fellowship program at the Centeno-Schultz Clinic. During his fellowship, he gained significant experience in the new field of Interventional Orthopedics and regenerative medicine, honing his skills in advanced injection techniques into the spine and joints treating patients with autologous, bone marrow concentrate and platelet solutions. Dr. Markle then accepted a full-time attending physician position at the Centeno-Schultz Clinic, where he both treats patients and trains Interventional Orthopedics fellows. Dr. Markle is an active member of the Interventional Orthopedic Foundation and serves as a course instructor, where he trains physicians from around the world.

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Brandon T. Money, D.O., M.S.

Dr. Money is an Indiana native who now proudly calls Colorado home. He attended medical school at Kansas City University and then returned to Indiana to complete a Physical Medicine and Rehabilitation residency program at Indiana University, where he was trained on non-surgical methods to improve health and function as well as rehabilitative care following trauma, stroke, spinal cord injury, brain injury, etc. Dr. Money has been following the ideology behind Centeno-Schultz Clinic and Regenexx since he was in medical school, as he believed there had to be a better way to care for patients than the status quo. The human body has incredible healing capabilities…

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Other Resources for Elbow Pain

References

1. Sun J, Chen F, Braun C, et al. Role of curcumin in the management of pathological pain. Phytomedicine. 2018;48:129-140. doi:10.1016/j.phymed.2018.04.045
2. Soheilifar S, Bidgoli M, Hooshyarfard A, Shahbazi A, Vahdatinia F, Khoshkhooie F. Effect of Oral Bromelain on Wound Healing, Pain, and Bleeding at Donor Site Following Free Gingival Grafting: A Clinical Trial. J Dent (Tehran). 2018;15(5):309-316.
3. Picado C, Luengo M. Corticosteroid-induced bone loss. Prevention and management. Drug Saf. 1996;15(5):347-359. doi:10.2165/00002018-199615050-00005
4. Bohlen, Hunter L., et al. “Platelet-rich plasma is an equal alternative to surgery in the treatment of type 1 medial epicondylitis.” Orthopaedic Journal of Sports Medicine 8.3 (2020): 2325967120908952.
5. Baumgard SH, Schwartz DR. Percutaneous release of the epicondylar muscles for humeral epicondylitis. Am J Sports Med. 1982 Jul-Aug;10(4):233-6. doi: 10.1177/036354658201000408. PMID: 7125045.