Anatomy
The elbow joint is the joint connection between the humerus and the two bones of the forearm: the radius and the ulna. Several ligaments reinforce the elbow joint: the medial collateral ligament, the lateral collateral ligament and the radial collateral ligament (which goes around the head of the radius). 5 of the forearm muscles responsible for wrist and finger flexion attach to the medial epicondyle of the humerus at the elbow: pronator teres, flexor carpi radialis, palmaris longus, flexor digitorum superficialis and flexor carpi ulnaris.
The flexor muscles of the forearm:
A. M. biceps brachii
B. Epikondylus mediale
C. Aponeurosis m. bicipitis brachii
D. M. pronator teres
E. M. flexor carpi radialis
F. M. palmaris longus
G. M. flexor digitorum superficialis
H. M. flexor carpi ulnaris
Cause
Repeated repetitive (over)loading (wrist flexion) exceeds the strength of the muscle attachment. This causes microscopic tears in the tendon and especially at the tendon attachment on the inside of the elbow (enthesitis), resulting in ‘inflammation’, which is most often seen in 45-64 year olds in the dominant arm. The tendonitis is a warning sign that the training is too strenuous for the current muscle tendon, and if the strain is not reduced, a chronic ‘inflammation’ can develop that is difficult to treat.
Also known as ‘golfer’s elbow’, in sports (golf, weightlifting, racket sports, bowling, javelin throwing, overhand throwing, etc.) this condition is often a result of incorrect technique and rapid escalation of training intensity, but can also occur for many other reasons. Using a new heavier racket, heavier balls or stiff club/racket are other factors that can cause symptoms.
It is especially the forehand stroke in tennis, tennis serve or smash (badminton) that triggers a heavy load on the muscle attachments inside the elbow (flexor tendons). 90% of cases of golf elbow are seen in non-athletes (Kiel J, Kaiser K. 2023), where heavy work, many repetitions, diabetes and tobacco smoking are risk factors.
Symptoms
Tenderness and pain on the bony prominence on the inside of the elbow (medial epicondyle) with aggravation when bending the wrist (flexion) against resistance and when stretching. The pain can radiate down the forearm.
Examination
Usually, the diagnosis is made during a general clinical examination where there is tenderness at the muscle tendon attachment on the inside of the elbow. If there is doubt about the diagnosis, an ultrasound scan can be performed where the inflammatory changes at the attachment can often be seen. Long-term discomfort can lead to swelling of the periosteum (‘enthesopathy’) and calcifications in the soft tissues. MRI scans are rarely indicated.
See ultrasound scan of the medial epidondyle showing normal conditions at the muscle tendon attachment.In golf elbow, the tendon attachment appears thickened, hypoeccotic (dark) and with blood vessel ingrowth (Doppler activity)
Treatment
Correcting the triggering cause (load, impact technique and equipment adaptation) is of course crucial to the outcome of rehabilitation.
The recommended treatment is relief from pain-inducing activity, stretching and slowly increasing strength training of the forearm muscles within the pain threshold.
If you take a break from or reduce the amount of the triggering sport, most people’s symptoms disappear within weeks to months, but it is not uncommon for the symptoms to last for several years, which is why it is important to correct training as soon as the first symptoms start.
If the discomfort does not subside, treatment can be supplemented with medical treatment in the form of adrenal cortex hormone, although the evidence for long-term effects is limited. If there is no improvement, surgery may be considered, although the evidence is limited. Surgery is only indicated in 2-3% of cases (Kiel J, Kaiser K. 2023).
Bandage
Some people notice an improvement in symptoms by applying tape (or a bandage) around the forearm just below the elbow, see tape. However, this treatment is also undocumented. Wrist and elbow bandages can provide relief, but there is a lack of evidence of effectiveness.
Complications
If no progress is made, you should reconsider whether the diagnosis is correct or if complications have arisen.
In particular, the following should be considered:
- Inflammation of the bursa at the elbow
- Rheumatoid arthritis in the elbow joint
- Ligament ruptures on the inside of the elbow
- Damage to the ulnar and median nerves
- Thrower’s elbow (discomfort triggered from the elbow joint itself and joint capsule)
- Muscle rupture
