What is the stepwise management of medial epicondylitis (golfer's elbow)?

Stepwise Management of Golfer's Elbow (Medial Epicondylitis)

The management of medial epicondylitis should begin with conservative measures including rest, activity modification, analgesia, physical therapy, and potentially corticosteroid injections, progressing to surgical intervention only for severe or refractory cases. 1

Initial Diagnosis and Assessment

• Radiographs are beneficial as the initial imaging for chronic elbow pain to rule out other pathologies such as intra-articular bodies, heterotopic ossification, osteochondral lesions, soft tissue calcification, or occult fractures 1
• Medial epicondylitis typically presents with pain at the medial aspect of the elbow and affects 1% of the general population, with higher prevalence (3.8-8.2%) in work-related complaints 2
• The condition is most common in the 40-60 year age group and affects both men and women equally 2, 3
• Physical examination may reveal tenderness at the common flexor tendon origin at the medial epicondyle 3

First-Line Treatment (Conservative Management)

1. Rest and Activity Modification

   • Avoid activities that require repetitive wrist flexion and forearm pronation 1, 3
   • Modify technique and equipment if sports or occupation is causative 3

2. Pain Management

   • Ice application to reduce inflammation 3
   • Nonsteroidal anti-inflammatory drugs (NSAIDs) for pain relief 1, 3

3. Physical Therapy and Rehabilitation

   • Eccentric strengthening exercises for the wrist flexors 1, 4
   • Range-of-motion exercises to maintain elbow mobility 3
   • Deep transverse friction massage to reduce pain 1
   • Golf-specific functional rehabilitation for athletes 5

4. Orthotic Devices

   • Counterforce bracing/medial epicondylitis strap to reduce strain on the common flexor tendon 3
   • Although commonly used, evidence for effectiveness is limited 1

Second-Line Treatment

1. Corticosteroid Injections

   • Consider for patients with persistent symptoms despite first-line treatment 1
   • More effective than NSAIDs in the acute phase but may not change long-term outcomes 1
   • Should be used judiciously due to potential side effects including tendon weakening 3

2. Alternative Therapies

   • Extracorporeal shock wave therapy (ESWT) has shown mixed results but may be considered 1, 2
   • Injectable blood derivatives (e.g., platelet-rich plasma) are emerging treatment options 2, 4

Third-Line Treatment (Surgical Intervention)

• Surgical treatment is indicated for debilitating pain that persists despite well-managed conservative treatment for at least 6 months 3
• Surgical technique typically involves:
  • Excision of the pathologic portion of the tendon
  • Repair of the resulting defect
  • Reattachment of the origin to the medial epicondyle 3
• Newer surgical techniques are being developed and applied 2

Prevention Strategies

• Implement a comprehensive strength and flexibility program 6, 5
• Proper warm-up exercises before activity 6
• Correct technique mechanics, especially for golf and throwing sports 6, 5
• Core strengthening, particularly of the transversus abdominis muscle, may help prevent recurrence in athletes 5

Common Pitfalls and Caveats

• Failure to rule out other causes of medial elbow pain such as ulnar neuropathy (cubital tunnel syndrome) 5, 4
• Premature return to aggravating activities before adequate healing 3
• Overreliance on corticosteroid injections without addressing underlying biomechanical issues 1, 3
• Patient non-compliance with rehabilitation programs, especially among enthusiastic golfers and athletes 5
• Inadequate attention to technique modification and equipment assessment 3