What are the treatment options for golfer's elbow (medial epicondylitis)?

Treatment Options for Golfer's Elbow (Medial Epicondylitis)

Begin with conservative management including rest, activity modification, NSAIDs for pain relief, and eccentric strengthening exercises for the wrist flexors, as these form the foundation of treatment for medial epicondylitis. 1, 2

First-Line Conservative Treatment

Activity Modification and Rest

• Avoid activities requiring repetitive wrist flexion and forearm pronation, which are the primary aggravating movements in medial epicondylitis 1, 2
• Relative rest to reduce repetitive loading of the damaged tendon is essential for healing 2

Pain Management

• NSAIDs provide short-term pain relief but do not affect long-term outcomes 2
• Cryotherapy (ice application) for 10-minute periods can provide acute pain relief 2

Exercise Therapy

• Eccentric strengthening exercises for the wrist flexors are critical to promote tendon healing and increase strength 1, 2
• Progressive strengthening exercises focusing on the flexor-pronator muscle group should be implemented 2
• Stretching exercises for the wrist flexors complement the strengthening program 2
• Deep transverse friction massage can reduce pain 1, 2

Equipment Modifications

• Medial counterforce bracing may be considered, though evidence for effectiveness is limited 2, 3
• Larger club grips can reduce strain on the medial epicondyle 3
• Graphite shafts may decrease stress on the elbow 3

Second-Line Treatment

Corticosteroid Injections

• Consider corticosteroid injections for persistent symptoms despite first-line treatment, as they are more effective than NSAIDs in the acute phase 1, 2
• These injections provide short-term pain relief but do not change long-term outcomes 2

Alternative Therapies

• Extracorporeal shock wave therapy (ESWT) has shown mixed results but may be considered as an alternative 1

Diagnostic Imaging Considerations

• Plain radiographs are the most appropriate initial imaging to rule out other pathologies such as intra-articular bodies, heterotopic ossification, osteochondral lesions, soft tissue calcification, or occult fractures 1, 2
• MRI may be considered if radiographs are normal and there is suspicion of tendon degeneration or tear 2

Common Pitfalls to Avoid

• Overreliance on corticosteroid injections without addressing underlying biomechanical issues is a major pitfall in management 1
• Amateur golfers demonstrate significantly increased pronator teres activity in the trail arm compared to professionals, suggesting that technique modification and specific strengthening of this muscle group may be therapeutic 4
• Shortening the backswing can decrease pressure on the medial epicondyle 3

Treatment Algorithm

Step 1: Initiate activity modification, NSAIDs, and eccentric strengthening exercises immediately 1, 2

Step 2: Add equipment modifications (larger grips, counterforce bracing) and physical therapy with deep friction massage 2, 3

Step 3: If symptoms persist beyond 6-8 weeks of conservative treatment, consider corticosteroid injection 1, 2

Step 4: For refractory cases, consider ESWT or surgical consultation 1