Medial Epicondylitis: Golfer’s Elbow Treatment

Medial epicondylitis (golfer’s elbow)

Medial epicondylitis, commonly known as golfer’s elbow (in English medial epicondylitis or golfer’s elbow), is a tendinopathy that affects the tendons of the forearm’s flexor and pronator muscles at their insertion on the medial epicondyle — the inner bony prominence of the elbow. It is the “cousin” of lateral epicondylitis (tennis elbow), with the difference that medial epicondylitis affects the inner side of the elbow, while lateral epicondylitis affects the outer side.

Despite its name, medial epicondylitis rarely affects golfers: it is much more common in people who perform manual labor with repetitive wrist flexion movements and strong gripping (masons, plumbers, cooks) and in athletes who practice throwing sports (baseball, javelin) or sports with strong gripping (climbing, weightlifting).

Conservative treatment with physiotherapy and exercises is effective in the majority of cases, with success rates of 85-90%.

Anatomy: The Medial Epicondyle and Flexor Muscles

The medial epicondyle (or medial epicondyle of the humerus) is the bony prominence palpable on the inner side of the elbow. The tendons of five muscles insert onto it:

• Pronator teres: pronates the forearm (rotates the palm downwards)
• Flexor carpi radialis: flexes the wrist
• Flexor digitorum superficialis: flexes the fingers
• Palmaris longus: tenses the palmar fascia
• Flexor carpi ulnaris: flexes and ulnarly deviates the wrist

The common tendon of these muscles is subjected to significant stress during wrist flexion, gripping, and forearm pronation movements. Repeated microtraumas cause a degenerative process (tendinosis) which, contrary to what the name “tendinitis” suggests, is more degenerative than inflammatory in chronic forms.

Relationship with the Ulnar Nerve

The ulnar nerve passes immediately adjacent to the medial epicondyle, in the “ulnar groove” (the “nerve channel” that everyone knows as the area where you feel a “shock” when hitting your elbow). In medial epicondylitis, inflammation and swelling can irritate the ulnar nerve, causing tingling in the little finger and ring finger. This symptom requires careful evaluation to rule out true ulnar neuropathy.

Causes and Risk Factors

Repetitive Movements

The causal mechanism is repetitive overload of the wrist flexor muscles:

• Manual labor: screwing, hammering, using pliers, lifting weights with a strong grip
• Sports: golf (swing follow-through), baseball (throwing), climbing, weightlifting, racket sports (technical error in the forehand)
• Daily activities: cooking (stirring, kneading), gardening, intense typing

Predisposing Factors

• Incorrect sports technique: in golf, too tight a grip or incorrect impact with the ground
• Inadequate equipment: rackets that are too heavy, grips that are too small or too large
• Muscle weakness: weak wrist flexors make them more vulnerable to overload
• Joint stiffness: limited mobility of the elbow or wrist
• Age: more common between 40 and 60 years old
• Smoking: reduces tendon vascularization
• Diabetes: predisposes to tendinopathies

Unlike mouse epicondylitis, which affects the outer side due to prolonged mouse use, medial epicondylitis is less related to computer work.

Symptoms

Pain

• Location: inner side of the elbow, on the bony prominence of the medial epicondyle
• Radiation: pain can radiate along the inner part of the forearm down to the wrist
• Worsening: with resisted wrist flexion, strong gripping, opening jars, shaking hands
• Onset: gradual, without a specific trauma. Starts as discomfort and progresses to constant pain

Weakness of Grip

Grip becomes weak and painful. Grasping objects, shaking hands, lifting a bottle or a pan become difficult actions.

Morning Stiffness

Stiffness and elbow pain upon waking, which improves with warming up.

Tingling (if ulnar nerve is involved)

In some cases, tingling in the 4th and 5th fingers (ring and little finger) indicates irritation of the ulnar nerve. This symptom requires evaluation by your doctor or physical therapist.

Difference between Medial Epicondylitis and Lateral Epicondylitis

The two conditions can coexist in the same elbow.

Diagnosis

Clinical Examination

• Palpation of the medial epicondyle: localized pain on the inner bony prominence
• Resisted wrist flexion test: the patient flexes the wrist against the examiner’s resistance with the elbow extended — reproduction of medial epicondyle pain is diagnostic
• Resisted pronation test: forearm pronation against resistance reproduces the pain
• Ulnar nerve evaluation: Tinel’s test (percussion of the ulnar groove), evaluation of sensation in the 4th and 5th fingers
• Comparison with the healthy side: grip strength is often reduced

Imaging Diagnostics

• Ultrasound: visualizes tendon degeneration, thickening, possible partial tears
• MRI: indicated in resistant cases or if a significant tendon injury is suspected
• X-ray: generally normal, may show calcifications of the medial epicondyle
• Electromyography: indicated if associated ulnar nerve neuropathy is suspected

Treatment

Acute Phase (0-4 weeks)

• Relative rest: avoid activities that trigger pain, but do not immobilize the elbow
• Ice: 15-20 minutes on the painful area after activities
• NSAIDs: as needed for pain control
• Epicondyle brace: a band placed on the inner part of the forearm, about 5 cm below the medial epicondyle, can reduce stress on the tendon
• Ergonomic modifications: analyze and modify work or sports activities that caused the problem

Physiotherapy

• Manual therapy: elbow mobilization, soft tissue gliding techniques
• Eccentric exercises: the cornerstone of treatment — eccentric exercises stimulate tendon repair
• Stretching: of the wrist flexor muscles
• Progressive strengthening: recovery of grip strength and wrist flexion
• Shockwave therapy: effective in resistant chronic forms
• Physical therapies: ultrasound, laser therapy

Injections

• Corticosteroids: effective in the short term (4-6 weeks) but with a risk of recurrence. Reserved for intense acute forms
• PRP (platelet-rich plasma): promising in resistant chronic forms

Exercises for Medial Epicondylitis

The medial epicondyle is the bony inner elbow prominence where wrist flexor tendons attach; medial epicondylitis causes gradual pain there with grip weakness from repetitive overload. The eccentric exercise program is the most effective long-term treatment. Your doctor or physical therapist will guide the progression.

Stretching

Wrist flexor stretch

[IMAGE: Person standing with the affected arm extended forward, elbow fully extended, palm facing upwards. The other hand grasps the fingers and gently pulls them downwards and towards the body, extending the wrist and stretching the forearm flexors. Front view with detail of wrist extension.]

Pronator stretch

[IMAGE: Person seated with the affected arm extended forward, elbow extended, palm facing upwards (full supination). The other hand grasps the hand and accentuates supination, stretching the forearm pronators. Front view with detail of forearm rotation.]

Eccentric Exercises

Eccentric wrist flexion with dumbbell

[IMAGE: Person seated with the forearm resting on a table, wrist and hand extending beyond the edge. The hand holds a small dumbbell (0.5-1 kg) with the palm facing upwards. The wrist is flexed (hand up), then slowly lowers downwards into controlled extension (eccentric). The upward phase is assisted by the other hand. Side view with detail of wrist movement.]

Eccentric pronation with hammer

[IMAGE: Person seated with the elbow flexed at 90 degrees, resting on a table. The hand holds a hammer (or an asymmetrical weight tool) in the vertical position (neutral position). The hammer slowly rotates inwards (eccentric pronation), controlling the descent. The other hand returns the hammer to the starting position. Front view with detail of rotation.]

Progressive Strengthening

Wrist flexion with resistance band

[IMAGE: Person seated with the forearm resting on a table, wrist extending beyond. A therapeutic resistance band is under the foot and held with the hand (palm upwards). The wrist flexes upwards against the resistance of the band, then slowly returns to the starting position. Side view.]

Grip strengthening with ball

[IMAGE: Person seated squeezing a stress ball (or a tennis ball) with the hand of the affected side. The fingers completely wrap around the ball and squeeze it for 5 seconds, then release. Detail of the hand showing forearm muscle contraction. Front view.]

Flexbar exercise (reverse twist)

[IMAGE: Person standing holding a Flexbar (flexible rubber cylinder) with both hands. The hand on the affected side is at the bottom with the wrist in flexion. The healthy hand (at the top) twists the Flexbar, then the affected hand slowly resists the untwisting (eccentric). Front view with detail of hand position and twist direction.]

Recovery Times

Consistency in eccentric exercises is crucial: the best results are obtained with a program of at least 8-12 weeks.

When is Surgery Necessary?

Surgery is indicated only after the failure of at least 6-12 months of adequate conservative treatment. The intervention consists of debridement (cleaning) of the degenerated tendon tissue and resection of the flexor origin. Results are generally good, but post-operative recovery requires 3-6 months.

Prevention

• Adequate warm-up: before intensive sports or work activities
• Correct technique: in golf, tennis, and racket sports
• Progressive strengthening: maintain strength of forearm flexors and pronators
• Regular stretching: after each activity session
• Appropriate equipment: grips of the right size, rackets not too heavy
• Breaks during repetitive activities: alternate hands, take breaks every 30-45 minutes
• Ergonomics: pay attention to wrist position during work

Frequently Asked Questions (FAQ)

Frequently Asked Questions

What are the primary causes of medial epicondylitis?

Medial epicondylitis is primarily caused by repetitive wrist flexion and strong gripping actions. This overuse can lead to microtrauma and degeneration of the tendons originating from the medial epicondyle. While often associated with golf, it is more common in occupations involving manual labor and certain throwing or gripping sports.

How is medial epicondylitis diagnosed?

Diagnosis of medial epicondylitis typically involves a thorough clinical examination by a healthcare professional. This includes assessing symptoms, palpating the affected area, and performing specific physical tests to evaluate pain and strength. Imaging diagnostics, such as ultrasound or MRI, may be used to confirm the diagnosis or rule out other conditions.

What are the main ways to treat golfer’s elbow without surgery?

Conservative treatment for medial epicondylitis often begins with rest and activity modification to reduce stress on the affected tendons. A physical therapist plays a crucial role in guiding a progressive exercise program, including stretching, eccentric exercises, and strengthening. Injections may also be considered as part of the treatment plan.

When is surgical intervention typically considered for medial epicondylitis?

Surgical intervention for medial epicondylitis is generally considered a last resort when extensive conservative treatment has failed to provide significant relief. This option is usually reserved for persistent cases where symptoms severely impact daily function and quality of life. The decision for surgery is made after careful evaluation by a medical specialist.

Sources and Scientific References

1. Landesa-Piñeiro L et al. (2022). Physiotherapy treatment of lateral epicondylitis: A systematic review. J Back Musculoskelet Rehabil. 35:463-477. DOI | PubMed
2. Lenoir H et al. (2019). Management of lateral epicondylitis. Orthop Traumatol Surg Res. 105:S241-S246. DOI | PubMed
3. Stasinopoulos D et al. (2004). Cyriax physiotherapy for tennis elbow/lateral epicondylitis. Br J Sports Med. 38:675-7. DOI | PubMed
4. Ciccotti MC et al. (2004). Diagnosis and treatment of medial epicondylitis of the elbow. Clin Sports Med. 23:693-705, xi. DOI | PubMed
5. Viswas R et al. (2012). Comparison of effectiveness of supervised exercise program and Cyriax physiotherapy in patients with tennis elbow (lateral epicondylitis): a randomized clinical trial. ScientificWorldJournal. 2012:939645. DOI | PubMed