“Hey doc! My elbow hurts.” – Unfortunately, this is not an uncommon thing I hear from people on the golf course, at the gym, or in 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 and is certainly not limited to the golfer or rock climber.
Personal note – I have a long history of medial epicondylitis since high school! Yes, I was and still am an avid golf enthusiast…and amateur rock climber. Until a few months ago, it was well managed with turmeric supplements, low sugar diet and the occasional prolotherapy injection. I increased my training intensity in the gym and started practicing for Long Drive golf competitions. The pain in my right elbow got to the point where needed something more. So I had one of our other doctors perform platelet-rich plasma (PRP) injections to the tendon, ulnar collateral ligament, and joint. Less than two weeks after treatment, I played 54 holes over a weekend (including 36 in one day) and only had mild soreness the day after. My elbow is feeling better than it has in a LONG time only a few weeks after being treated.
What Is Golfer’s Elbow?
Golfer’s elbow involves tears in the ulnar collateral ligament and pain or soreness on the inside of the elbow. The bony bump you feel there is the medial epicondyle of the humerus (upper arm bone). There are five forearm muscles that attach at this point, all of which are involved in helping to flex or rotate the forearm and wrist. Pain can get worse when you throw a ball, grip a dumbbell, turn a screwdriver, and other movements that involve the fingers, hand, wrist, and/or 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 extension. It is actually much more common than golfer’s elbow but is generally treated in a similar fashion.
What Causes this Forearm 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, there are other issues that can result in 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 like 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.
How Is Golfer’s Elbow Diagnosed?
A trained musculoskeletal physician is usually able to diagnose golfer’s elbow by talking with you about your history and performing a physical exam. Those who are experts in diagnostic ultrasound imaging may do this in the office in order to assess for any tendon abnormalities such as swelling or tears. 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 or nerve conduction tests are done to rule out other issues.
What Are My Treatment Options?
Conservative treatment with rest, stretching, counterforce bracing, natural anti-inflammatories such as turmeric and bromelain is a good place to start. Chronic use of medications such as ibuprofen (Advil) and naproxen (Aleve) are not recommended as they block inflammation, which is required for the healing process to occur. They have also been shown to negatively impact the gastrointestinal (GI), cardiovascular and renal systems1. 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. Although they may mask the pain for a short period of time, they are doing nothing to heal the tissue and can actually cause MORE injury to tendon cells and cartilage2,3.
If conservative treatment does not provide sufficient relief of symptoms, a safe injection-based treatment from Centeno-Schultz Clinic may be recommended. 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 production4,5.
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 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 patients6.
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.
Surgery for this issue should be a LAST resort. I would not recommend even considering surgery until all of the above options have been tried. 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.
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. It definitely did to me. Reach out to the Centeno-Schultz Clinic education center to schedule an appointment. Rest assured that you will receive a treatment plan for Golfer’s elbow personalized for you, designed to target the cause of injury and boost your body’s ability to heal.
1– Laine L. Gastrointestinal effects of NSAIDs and coxibs. J Pain Symptom Manage. 2003 Feb;25(2 Suppl):S32-40.
2– Dean BJ, Franklin SL, Murphy RJ, Javaid MK, Carr AJ. Glucocorticoids induce specific ion-channel-mediated toxicity in human rotator cuff tendon: a mechanism underpinning the ultimately deleterious effect of steroid injection in tendinopathy?. Br J Sports Med. 2014;48(22):1620‐1626.
3– McAlindon TE, LaValley MP, Harvey WF, et al. Effect of Intra-articular Triamcinolone vs Saline on Knee Cartilage Volume and Pain in Patients With Knee Osteoarthritis: A Randomized Clinical Trial. JAMA.2017;317(19):1967–1975.
4– Ekwueme EC, Mohiuddin M, Yarborough JA, Brolinson PG, Docheva D, Fernandes HAM, Freeman JW. Prolotherapy Induces an Inflammatory Response in Human Tenocytes In Vitro. Clin Orthop Relat Res. 2017 Aug;475(8):2117-2127.
5– Hung CY, Hsiao MY, Chang KV, Han DS, Wang TG. Comparative effectiveness of dextrose prolotherapy versus control injections and exercise in the management of osteoarthritis pain: a systematic review and meta-analysis. J Pain Res. 2016;9:847-857.
6- Bohlen HL, Schwartz ZE, Wu VJ, Thon SG, Finley ZJ, O’Brien MJ, Savoie FH 3rd. Platelet-Rich Plasma Is an Equal Alternative to Surgery in the Treatment of Type 1 Medial Epicondylitis. Orthop J Sports Med. 2020 Mar 25;8(3):2325967120908952.