Management of Golfer's Elbow Exacerbation
For an acute exacerbation of golfer's elbow (medial epicondylitis), initiate immediate relative rest with activity modification, ice application for 10-minute periods through a wet towel, oral or topical NSAIDs for pain relief, and medial counterforce bracing, while avoiding activities that reproduce the pain. 1, 2
Initial Management (0-4 Weeks)
Activity Modification and Rest
- Relative rest is the cornerstone of treatment to prevent ongoing tendon damage and promote healing 1
- Stop or modify activities that aggravate symptoms (gripping, resisted wrist flexion, golf swings) 1, 3
- Continue activities that don't worsen pain to prevent muscular atrophy from complete immobilization 1
Pain Control Modalities
- Apply ice (cryotherapy) for 10-minute periods through a wet towel for effective short-term pain relief 1
- NSAIDs (oral or topical) provide effective pain relief during the acute phase 1, 3
- Topical NSAIDs reduce tendon pain while avoiding gastrointestinal side effects of oral formulations 1
Bracing and Equipment Modifications
- Medial counterforce bracing helps unload and protect the flexor-pronator tendon origin 2
- Consider larger club grips and graphite shafts if the patient continues golfing 2
Rehabilitation Phase (2-8 Weeks)
Progressive Exercise Program
- Eccentric strengthening exercises promote tendon healing and increase strength once acute pain subsides 1
- Stretching exercises for the wrist flexors are widely accepted and beneficial 1
- Tensile loading stimulates collagen production and guides proper alignment of newly formed collagen fibers 1
Continued Supportive Care
- Continue bracing as needed during activities 1
- Heat modalities including ultrasound may be introduced after the acute phase 3
Second-Line Treatments for Persistent Symptoms
Corticosteroid Injections
- Locally injected corticosteroids may be more effective than NSAIDs for acute phase relief 1
- Use with extreme caution as they do not alter long-term outcomes and may inhibit healing, reduce tendon tensile strength, and predispose to spontaneous rupture 1, 3
- Consider only to create a pain-free window for optimizing rehabilitation exercises 3
Alternative Modalities
- Therapeutic ultrasound may decrease pain and increase collagen synthesis, though evidence is weak 1
- Deep transverse friction massage can reduce pain 1
Surgical Consultation (>6-12 Months)
- Surgical evaluation is warranted only after 6-12 months of well-managed conservative treatment fails 1, 4
- Surgery involves excision of pathologic tendon tissue and longitudinal tenotomies to release scarring and fibrosis 1, 4
- Surgical treatment results in high subjective relief, though objective strength deficits may persist 4
Critical Pitfalls to Avoid
- Never overrely on corticosteroid injections as they may lead to tendon weakening and potential rupture 1
- Avoid complete immobilization which leads to muscle atrophy and deconditioning 1
- Ensure proper diagnosis with plain radiographs to rule out fractures, heterotopic ossification, or osteoarthritis 5
- Address biomechanical factors including golf swing technique and equipment to prevent recurrence 2, 6, 3