A Patient’s Guide to Medial Epicondylitis (Golfer’s )

OrthoVirginia 1115 Boulders Parkway Sutie 200 Richmond, VA 23225 Phone: 804-560-5595 Fax: 804-560-9029

Compliments of: OrthoVirginia DISCLAIMER: The information in this booklet is compiled from a variety of sources. It may not be complete or timely. It does not cover all diseases, physicalA conditions, Patient's ailments Guide or treatments. to TheMedial information Epicondylitis should NOT be used (Golfer’sin place of a visit Elbow) with your health care provider, nor should you disregard the advice of your health care provider because of any information you read in this booklet.

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epicondyle. Wrist flexors are the muscles of the that pull the forward. The wrist flexors are on the palm side of the forearm. Most of the wrist flexors attach to one main on the medial epicondyle. This tendon is called the common flexor tendon. connect muscle to bone. Tendons are made up of strands of a material called collagen. The collagen Introduction strands are Collagen lined up in Medial epicondylitis is commonly known as bundles next to each other. golfer's elbow. This does not mean that only golfers have this condition. But the golf Because the collagen strands in tendons are swing is a common cause of medial epicon- lined up, tendons have high tensile strength. dylitis. Many other repetitive activities This means they can withstand high forces that can also lead to golfer's elbow: throwing, pull against both ends of the tendon. When chopping wood with an ax, running a chain muscles work, they pull on one end of the saw, and using many types of hand tools. tendon. The other end of the tendon pulls on Any activities that stress the same forearm the bone, causing the bone to move. muscles can cause symptoms of golfer's The wrist flexor muscles contract when you elbow. flex your wrist, twist your forearm down, or This guide will help you understand grip with your hand. The contracting muscles • what parts of the elbow are affected pull on the flexor tendon. The forces that pull • what causes golfer's elbow on the tendon can build when you grip a golf • how to make the pain go away club during a golf swing or do other similar actions. Causes Anatomy Why did I develop golfer's elbow? What parts of Overuse of the muscles and tendons of the the elbow are forearm and elbow are the most common affected? reason people develop golfer's elbow. Golfer's elbow Repeating some types of activities over and causes pain that over again can put too much strain on the starts on the elbow tendons. These activities are not neces- inside bump sarily high-level sports competition. Shoveling, of the elbow, gardening, and hammering nails can all cause the pain of golfer's elbow. Swimmers who the medial Medial epicondyle

3 Compliments of: OrthoVirginia A Patient's Guide to Medial Epicondylitis (Golfer’s Elbow) try to pick up speed by powering their No one really knows exactly what causes through the water can also strain the flexor tendinosis. Some doctors think that the forearm tendon at the elbow. tendon develops small tears with too much activity. The tears try to heal, but constant In some cases, the symptoms of golfer's strain and overuse keep re-injuring the tendon. elbow are due to inflammation. In an acute After a while, the tendons stop trying to heal. injury, the body undergoes an inflammatory The scar tissue never has a chance to fully response. Special inflammatory cells make heal, leaving the injured areas weakened and their way to the injured tissues to help them painful. heal. Conditions that involve inflammation are indicated by -itis on the end of the word. For Symptoms example, inflammation in a tendon is called What does golfer's elbow feel like? tendonitis. Inflammation around the medial epicondyle is called medial epicondylitis. The main symptom of golfer's elbow is tender- ness and pain at the medial epicondyle of However, the elbow. Pain usually starts at the medial golfer's elbow epicondyle and may spread down the forearm. often is not Bending your wrist, twisting your forearm caused by down, or grasping objects can make the pain inflammation. worse. You may feel less strength when Rather, it is a grasping items or squeezing your hand into a problem within fist. the cells of the tendon. Doctors call this condi- tion tendinosis. In tendinosis, wear and tear is thought to lead to tissue degeneration. A degenerated tendon usually has an abnormal arrangement of collagen fibers. Instead of inflammatory cells, the body produces a type of cells called fibroblasts. When this happens, the collagen loses its strength. It becomes fragile and can break or be easily injured. Each time the collagen breaks down, Diagnosis the body responds How can my doctor be sure I have golfer's by forming elbow? scar tissue in Your doctor will first take a detailed medical the tendon. history. You will need to answer questions Eventually, about your pain, how your pain affects you, the tendon your regular activities, and past injuries to your becomes thick- elbow. ened from extra scar The physical exam is often most helpful in tissue. diagnosing golfer's elbow. Your doctor may

4 Compliments of: OrthoVirginia A Patient's Guide to Medial Epicondylitis (Golfer’s Elbow) position your wrist and arm so you feel a anti-inflammatory medication. Its benefits are stretch on the forearm muscles and tendons. temporary, but they can last for a period of This is usually painful with golfer's elbow. weeks to several months. Other tests for wrist and forearm strength are Shock wave therapy is a newer form of nonsur- used to help your doctor diagnose golfer's gical treatment. It uses a machine to generate elbow. shock wave pulses to the sore area. Patients You may need to get X-rays of your elbow. generally receive the treatment once each week The X-rays mostly help your doctor rule out for up to three weeks. It is not known exactly other problems with the elbow joint. The X- why it works for golfer's elbow, but recent ray may show if there are calcium deposits on studies indicate that this form of treatment the medial epicondyle at the connection to the can help ease pain, while improving range of flexor tendon. motion and function. Golfer's elbow symptoms are very similar to a Doctors commonly have their patients with condition called syndrome. This golfer's elbow work with a physical or occu- condition is caused by a pinched ulnar nerve pational therapist. At first, your therapist will as it crosses the elbow on its way to the hand. give you tips on how to rest your elbow and If your pain does not respond to treatments for how to do your activities without putting extra golfer's elbow, your doctor may suggest tests strain on your elbow. Your therapist may apply to rule out problems with the ulnar nerve. tape to take some of the load off the elbow muscles and tendons. You may use an elbow When the diagnosis is not clear, the doctor strap that wraps around the upper forearm in may order other special tests, such as a a way that relieves the pressure on the tendon magnetic resonance imaging (MRI) scan or attachment. ultrasound. An MRI scan uses magnetic waves to create pictures of the elbow in slices. The Your therapist may apply ice and electrical MRI scan shows tendons as well as bones. stimulation to ease pain and improve healing of the collagen. Therapy sessions may also Ultrasound tests use high-frequency sound include iontophoresis, which uses a mild waves to generate an image of the tissues electrical current to push anti-inflammatory below the skin. As the small ultrasound device medicine to the sore area. This treatment is rubbed over the sore area, an image appears is especially helpful for patients who can't on a screen. This type of test can sometimes tolerate injections. Exercises are used to show collagen degeneration. gradually stretch and strengthen the forearm Treatment muscles. How can I make my pain go away? Because tendinosis is often linked to overuse, your therapist will work with you to reduce Nonsurgical Treatment repeated strains during activity. When The key to nonsurgical treatment is to keep the symptoms are from a particular sport or work collagen from breaking down further. The goal activity, your therapist will observe your style is to help the tendon heal. and motion with the activity. Your therapist may suggest ways to protect the elbow during If the problem is caused by inflammation, anti- your activities. Your therapist can also check inflammatory medications such as ibuprofen your sports equipment and work tools and may give you some relief. If inflammation recommend ways to alter them to keep your doesn't go away, your doctor may inject the elbow safe. elbow with cortisone. Cortisone is a powerful

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Surgery Some surgeons suture the loose Sometimes nonsurgical treatment fails to stop end of the the pain or help patients regain use of the tendon to the elbow. In these cases, surgery may be neces- nearby sary. tissue. (Fascia Tendon Debridement tissue covers the muscles When problems are caused by tendinosis, and organs surgeons may choose to take out (debride) throughout only the affected tissues within the tendon. In your body.) these cases, the surgeon cleans up the tendon, removing only the damaged tissue. Your surgeon Tendon Release will look at the ulnar nerve, to A commonly make sure that used surgery it is not being for golfer's pinched. If the elbow is called nerve looks a medial fine, the skin epicondyle is then stitched release. This together. surgery takes tension off This surgery can the flexor usually be done on an outpatient basis, which tendon. The means that you don't have to stay overnight surgeon begins in the hospital. It can be done using a general by making an incision along the arm over anesthetic or a regional anesthetic. A general the medial epicondyle. Soft tissues are gently anesthetic puts you to sleep. A regional anes- moved aside so the surgeon can see the point thetic blocks only certain nerves for several where the flexor tendon attaches to the medial hours. For surgery on the elbow, you would epicondyle. most likely get an axillary block toto nnumbumb yyourour arm. The flexor tendon is then Rehabilitation cut where it How soon can I use my elbow again? connects to the medial epicon- Nonsurgical Rehabilitation dyle. The In cases where the tendon is inflamed, nonsur- surgeon splits gical treatment is usually only needed for four the tendon to six weeks. When symptoms are from tendi- and takes out nosis, you can expect healing to take longer, any extra scar usually up to three months. If the tendinosis is tissue. Any chronic and severe, complete healing can take bone spurs found on the medial epicondyle up to six months. are removed. (Bone spurs are pointed bumps that can grow on the surface of the bones.)

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After Surgery At about six weeks, you start doing more active strengthening. As you progress, your Recovery from surgery takes longer. therapist will give you exercises to help Immediately after surgery, your elbow is strengthen and stabilize the muscles and joints placed in a removable splint that keeps your of the wrist, elbow, and . You'll also elbow bent at a 90-degree angle. Ice and do exercises to improve fine motor control and electrical stimulation treatments may be used dexterity of the hand. Some of the exercises during your first few therapy sessions to help you'll do are designed to work your hand and control pain and swelling from the surgery. elbow in ways that are similar to your work Your therapist may also use massage and other tasks and sport activities. Your therapist will types of -on treatments to ease muscle help you find ways to do your tasks that don't spasm and pain. put too much stress on your elbow. You will gradually work into more active You may need therapy for two to three stretching and strengthening exercises. You months. It may take four to six months to get just need to be careful to avoid doing too back to high-level sports and work activities. much, too quickly. Active therapy starts about Before your therapy sessions end, your thera- two weeks after surgery. Your therapist may pist will teach you a number of ways to avoid begin with light isometric strengthening exer- future problems. cises. These exercises work the muscles of the forearm without straining the healing tissues. You will use your own muscle power in active range-of-motion exercises.

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Notes

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