What are the key components of a physical exam for golfer's elbow?

Physical Examination for Golfer's Elbow (Medial Epicondylitis)

A comprehensive physical examination for golfer's elbow should include assessment of pain at the medial epicondyle, resisted wrist flexion and forearm pronation tests, and evaluation for associated pathologies. 1

Anatomical Basis

• Medial epicondylitis involves degeneration of the flexor-pronator tendon origin at the medial epicondyle, typically resulting from repetitive forced wrist extension and forearm supination during activities involving wrist flexion and forearm pronation 1
• This condition predominantly affects amateur athletes and patients over 40 years of age who participate in sports requiring repeated forearm pronation and wrist flexion 2

Key Physical Examination Components

Inspection

• Look for visible swelling or erythema around the medial epicondyle 3
• Observe for any obvious deformity or muscle atrophy in the forearm flexor muscles 1

Palpation

• Localize tenderness at the medial epicondyle and the common flexor tendon origin 1
• Palpate along the course of the flexor-pronator mass to identify the specific area of maximum tenderness 3

Special Tests

• Resisted Wrist Flexion Test: Have the patient flex the wrist against resistance; positive test reproduces pain at the medial epicondyle 3
• Resisted Forearm Pronation Test: Have the patient pronate the forearm against resistance; positive test reproduces pain at the medial epicondyle 1
• Golfer's Elbow Test: Apply pressure to the medial epicondyle while the patient performs resisted wrist flexion; positive test reproduces the patient's symptoms 2

Range of Motion Assessment

• Evaluate active and passive elbow flexion, extension, pronation, and supination 4
• Compare with the contralateral side to identify any limitations 4

Neurological Examination

• Test for ulnar nerve symptoms (tingling, numbness in the 4th and 5th digits) as the ulnar nerve passes close to the medial epicondyle 1
• Perform Tinel's test at the cubital tunnel to assess for ulnar nerve involvement 4

Differential Diagnosis Assessment

• Assess for medial collateral ligament (MCL) insufficiency using valgus stress test 5
• Evaluate for posteromedial impingement by examining for pain during late cocking or early acceleration phases of throwing motion 1
• Rule out cervical radiculopathy and other referred pain sources 3

Imaging Considerations

• The American College of Radiology recommends radiography as the initial imaging for elbow pain to rule out other pathologies such as intra-articular bodies, heterotopic ossification, or occult fractures 6, 7
• If radiographs are normal or indeterminate and tendon or ligament injury is suspected, ultrasound or MRI without IV contrast is appropriate for further evaluation 6
• MRI has high inter- and intraobserver reliability for diagnosing epicondylalgia, with specific findings including intermediate to high T2 signal within the common flexor tendon and paratendinous soft tissue edema 6

Common Pitfalls

• Failing to differentiate between acute epicondylitis (inflammation) and chronic epicondylosis (structural changes in the tendon) 3
• Not assessing for concomitant ulnar neuropathy, which can coexist with medial epicondylitis 1
• Overlooking potential cervical spine or shoulder pathology that may refer pain to the elbow 3