Golfer’s elbow is a condition which gives rise to pain and weakness in the tendons in the elbow which attach the muscles of the forearm with the inner elbow usually as a result of overuse.
It arises due to overloading of the flexor tendons of the forearm and is often associated with increased periods of unaccustomed strenuous activity with the forearm muscles. Common examples may be an increase in computer use (especially if there is a poor ergonomic setup), DIY tasks involving gripping and twisting with the wrist/hand and sometimes racket sports.
It is often referred to as a ‘Golfer’s Elbow’ due to the fact that this tendon bears high load when playing golf. Excessive right wrist flexion (bending the wrist in the direction of the palm) in a right handed golfer may be responsible.
Although golf players can develop a ‘golfers elbow’ the vast majority of individuals who develop symptoms do so as a result of repetitive flexion at the wrist while performing lifting and carrying tasks. Hence the term medial epicondylitis is frequently used.
Localised pain is felt directly over the common flexor tendon in the inner elbow which sometimes radiates down the inside of the forearm muscle bulk.
Symptoms are aggravated by any activity which requires forceful flexion of the forearm muscles such as gripping, lifting and carrying tasks.
A medial epicondylitis can be reliably diagnosed by your doctor or physiotherapist by taking a history of your condition. In some circumstances it may be necessary to conduct a physical examination but this is usually not necessary.
The main feature is usually pain directly over the tendon when contracting the forearm muscles (when gripping or resisting wrist flexion).
It can be managed very effectively by adhering to the following advice and exercise routine.
Modifying aggravating activities. If there are some particularly stressful tasks such as golf or DIY which seem to be aggravating your symptoms, then the common flexor tendon may need 4-6 weeks of relative rest initially to settle symptoms while you work on strengthening the wrist flexor muscles in the forearm and the common flexor tendon (see below):
Exercises. Regular exercises to strengthen the wrist flexor muscles and tendon in the forearm and stretch the extensor muscles:
3×15 repetitions 3-4x per week
5×30 second holds, 2x per day
These are suggested exercises only. If you are at all concerned about whether these exercises are suitable for you or if you experience any pain while doing them, please seek appropriate clinical advice from your GP or Physiotherapist.
Corticosteroid injection therapy. Injections may be discussed with individuals who continue to suffer disabling pain (preventing work and leisure activities) and have failed physiotherapy management. You can read more about local corticosteroid injections here.
Your consultant will examine the elbow, and may use imaging technology to view the joint and rule out other causes of pain. You may be prescribed medication to treat the pain and inflammation. You will be required to rest your elbow and abstain from sports or heavy activities for a short time, and you may have to wear a splint to support your elbow.
You may be required to attend physiotherapy sessions which are often a very effective and evidenced based treatment for tennis elbow. Exercises involve gradually strengthening exercises for the forearm muscles which gradually increase the amount of load, thereby strengthening the affected tendon. In severe cases, you may require injections into the elbow joint to relieve swelling and pain.
In some cases, an operation will be required to release the inflamed tendon, debride it and repair where necessary.
Shoulder and elbow surgery can result in considerable pain and discomfort after the operation. Traditional painkillers are not always effective and have side effects. We usually offer you a local anaesthetic “block” to reduce the pain and discomfort following the procedure and also allow early more comfortable physiotherapy (if required). This consists of an injection at the side of your neck onto the nerves that supply your shoulder. The injection itself is fairly painless.
The procedure is carried out before the start of your operation. You will have a small plastic tube placed in your arm (drip). Then you may have some sedation to make you feel relaxed. A small numbing injection in the skin is placed prior to the block needle (which is smaller than a blood-taking needle). Your arm will then start to feel very heavy and numb (a similar sensation to when you have been lying on it). This spreads down the outside of the arm (and spares the inside).
Surgery is then carried out under sedation (you are comfortable, relaxed and either awake or sleeping if you prefer) or occasionally under general anaesthesia (you are unconscious and unaware). If you are awake, you are welcome to watch the procedure on a TV screen, and we will explain to you what is happening. If you require any extra pain relief during the procedure, we can easily give you this through your drip. The block will reduce the overall amount of painkilling drugs that you will require during and after the operation.
After your operation
The numbness will usually last for between 8 and 24 hours (depending on anaesthetic mixture used). We will leave your arm in a sling; please protect your arm whilst it is numb.
You will initially experience some ‘pins and needles’ as the block wears off and then some pain. Please prepare for this by taking the painkillers that we provide. Start these before the block wears off and expect to need them regularly for around 48hrs.
Occasionally we may recommend that at the time of the block we also place a small tube (catheter) that is fixed in place and through which we can give you further local anaesthetic to prolong your numbness for a few days. We would recommend this in situations where your pain after the operation is likely to be severe.
Complications of Anaesthesia
Anaesthesia is fairly safe for most people. If your health is not good the risks may be increased. Commoner complications include nausea and sore throat.
Local anaesthetic nerve blocks are generally considered to be safe. There is an approximately 5% (1 in 20) chance that they will fail or not work as well as expected. They tend to cause a small pupil and droopy eyelid temporarily and you may notice a hoarse voice or slight breathlessness.
Rare complications include reactions to the local anaesthetic solutions and nerve injury (the risk of temporary nerve symptoms e.g. tingling, numbness or weakness for a limited period is around 1 in 100 blocks and the overall risk of permanent injury approximately 1 in 5,000- 10,000 injections).
Paracetamol and an anti-inflammatory drug (if suitable for you – usually ibuprofen or diclofenac) are often used in combination. Take these regularly for the first few days.
Your anaesthetist will talk to you about strong painkillers, usually codeine, tramadol, oxycodone or morphine. Take these if your pain is poorly controlled (instructions will be on the packet). Some patients experience light-headedness when taking stronger painkillers; so be careful especially at first (rest up after taking them, don’t carry hot drinks or anything sharp) and take them only to counteract severe discomfort. Nausea and constipation can also occur, so drink plenty of water and increase the fibre in your diet; occasionally laxatives may be required (available from chemists).
If you are discharged on the same day as your operation, there should be someone keeping an eye on you during the first 24 hour period. If the painkillers make you excessively drowsy, then your carer needs to rouse you and ensure you not too sensitive to them.
Emergency contact numbers will be available on your discharge information if you or your carer wishes to talk to a trained member of staff.
Depending on the treatment required you should be able to return home the same day, but your recovery time is dependent on the severity of the injury. Your consultant will advise you and answer any questions you may have.
If a surgical release is considered, this is a generally safe procedure but there are some potential complications you should be aware of. These affect a very small percentage of patients.
- Infection can occur although our theatres have ultra-clean air operating conditions keeping infection rates to the minimum.
- Blood clots are possible after any operation and are more common in patients with some pre-existing medical conditions. However, again they affect a very small percentage of patients and have well established treatments including aspirin.
- Very rarely, damage to the nerves around the elbow leading to numbness, pain and in some cases weakness in the hand - this usually settles on its own.
- There may be continued pain in the elbow following the surgical release.