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Golfer's Elbow (medial epicondylitis) This is the tennis elbow of the inner aspect of the arm. Although it is somewhere between 7-10 times less common than Tennis Elbow, Golfer's Elbow affects patients in the 4th or 5th decades of life and is aggravated by wrist flexion or bending the wrist downwards. Anatomy The five muscles attached to the inner aspect of the elbow are part of the bone called the common flexor origin. Theories about the causes of this syndrome are varied and there is certainly no conclusive evidence, but the general opinion is the fact that there may have been some form of micro-trauma or micro tear of the attachment of these muscles to the bone, i.e. the tendonous attachment, which during activity or due to ageing, tend not to heal and may pull off the bone. This generally occurs in 40-60-year olds and much less commonly than Tennis Elbow. There is no association with any form of repetitive work or particular occupation. A condition such as Tennis Elbow does have a natural history in the fact that it generally gets better within 18 months. Clinical findings On examination, there is tenderness over the inner aspect of the elbow. There is obviously a very localised area of tenderness that the physician can identify in many incidences. Resisted hyperflexion of the wrist (pushing the wrist forward) can cause pain over the elbow. Treatment Options Golfer's Elbow splints are available from sports shops and may be of some benefit. Steroid injections, a mixture of Kenalog and a long-acting anaesthetic, can be injected into the local tender spot. This is slightly risky because there is a major nerve that runs just behind this bony prominence. This is called the ulnar nerve (your funny bone). If the injection is painful, it is more likely to work, however there is no proof that this makes any difference to the long-term outcome of the condition. Surgery This tends to be used when the condition has been going on longer than 18 months. Surgery, I regard as being only 50% successful. One advantage of it is, that it is unlikely to do much harm. If I do this operation, I always decompress the ulnar nerve at the same time (see Cubital Tunnel Syndrome). Operation Details Golfer's Elbow. This is the name given to what is thought to be a chronic tear of the attachment of the five muscles that bend the wrist forward or flex the wrist. It is common in 40 to 60-year olds and more common in ladies than men. This operation in Mr Field's opinion, shouldn't be performed before the patient has tried conservative measures for a period of 18 months, as a lot of cases will resolve on their own. Anaesthetic General or regional anaesthetic. Operative procedure An incision is made over the area and extended a little bit more up towards the arm. It is important that the ulnar nerve is identified (this is a major nerve that comes down to supply all small muscles of the hand and it goes just behind the bone where all these muscles attach). This must be identified and the nerve I think should be released at the same time. Once the ulnar nerve as been released then the common extensor origin can be cut in a circular fashion around the common extensor origin. The muscle and tendon are then stripped or dissected in a sharp fashion, away from the bone. The tendon is then left in situ and the wound is sewn up. Post-Operatively A sticky dressing is placed over the wound. A bulky bandage is placed over the elbow which is to be maintained for two weeks. The bandage can be removed at one week, but the dressing should not be taken off for a further week. Review in outpatients at two weeks. Return to work Patients can normally return to work between two to four weeks after the operation. Complications Not improving pain, which can occur in 50% of patients. Infection - this is a rare occurrence around the elbow and can be treated simply with antibiotics Stiffness - pretty rare Complex Regional Pain Syndrome |
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