Fig 1. Steroid injection for golfers elbow at the medial epicondyle.

Fig 2. Steroid injection for golfers elbow at the medial epicondyle.

History
Causes medial elbow pain that is activity related, and due to the mechanical overload of part of the Common Flexor Tendon Origin (mainly the origin of the Pronator Teres and Flexor Carpi Radialis); these muscles pronate and flex the wrist and forearm.
1/3 as common as tennis elbow. Only 10% of patients are golfers !
4:1 men, aged 30-50.
50% have associated ulnar nerve symptoms (cubital tunnel syndrome). Always ask about pins and needles symptoms.

Examination
Tenderness over anterior medial epicondyle facet.
Provocative test= pain on resisted forearm pronation with elbow extended, or pain on resisted wrist flexion.
Test the ulna nerve (see cubital tunnel information)

Differential Diagnosis

• Biceps tendinitis. Pain on elbow flexion and supination.
• Elbow arthritis. Often crepitus noted in elbow on movement.
• Rule out more proximal pathology from neck and shoulder.

Investigations
Usually a clinical diagnosis.
MRI scan if symptoms and signs are not fully clear to make a diagnosis.
X-Ray of elbow to rule out arthritis.
Nerve conduction studies if concern about ulnar nerve.

Treatment
50-90 % get better over a period of 6-18 months with conservative treatment, which includes

• Activity modification. Stop doing activities which cause it.
• Medication – NSAID’s
• Steroid Injection – See below for further information.
• Splints – Wrist flexion splint – protects the FCR, Counterforce brace (golfers elbow clasp) – spreads load at the elbow.
• Physio – Can be very helpful. Includes ultrasound, strengthening programmes,  acupuncture.
• Surgery – Only consider after at least 9/12 of the above. Success rate of around 70-90%. Can take up-to 9/12 to gain full affect. Warn patient.
• Shockwave – This technique utilises sound waves passed through the painful area to set in process an inflammatory response which in turn settles the symptoms down via the bodies natural healing process. Success rate is in the order of 60-70%.
•  Stem Cell Injection. A newish technique, which has good prelimary results with low complication rate and quicker rehab than open surgery.

When to Refer

• If diagnosis is not fully clear.
• If conservative treatments have failed after a period of 6-9/12.

Injections
Please refer to section on steroid injections.

How to Inject

• Blue needle
• 2mls Lignocaine, 20mgs Kenalog
• Aim for anterior facet of medial epicondyle
• Pepper pot technique (i.e multiple stabs/movements around the epicondyle during injection). This spreads the injection, but also causes bleeding which is good (as leads to scar tissue)
• protect ulna nerve (and check it is not situated infront of the epicondyle, which can rarely be the case)
• Rest for a week