GOLFERS ELBOW (medial epicondylitis)
What is golfers elbow (medial epicondylitis)?
Golfers elbow is a moderately common condition caused by degeneration at the attachment of the muscles to the outer side of the elbow joint. It is, however, much less common than tennis elbow. It occurs on the inner side of the elbow but is probably involving the same pathological processes, i.e. problems at the site of muscular attachment into bone. In some cases, however, the symptoms will be very similar to ulnar neuritis (cubital tunnel syndrome) and, in fact, be due to ulnar nerve entrapment (see information sheet).
Patients are typically between 40 and 60 years old. They typically present with pain on the inner side of the elbow, worse with use, particularly heavy lifting and gripping. This may be sufficient to cause a substantial reduction in their grip strength. It may become very severe such that they hardly use that elbow, wrist or hand at all. There may be some localised swelling, although this is uncommon.
Occasionally this may be associated with some numbness and tingling in the ring and little fingers of that hand which raises suspicion of some irritability at the ulnar nerve which runs around the back of the medial epicondyle (the prominent bone on the inner side of the elbow).
Why does it occur?
The anatomy of the area is that the muscles that straighten the wrist in particular and also the fingers come off the bony prominence on the inner side of the elbow (medial epicondyle) and local soft tissues. The attachment of muscle to bone is a very clever system whereby the muscle merges into cartilage which merges into the bone. This attachment is very strong but it would appear that, as with so many other problems of ageing, it becomes less robust in middle age i.e. this is a degenerative rather than an inflammatory process (hence the name epicondylitis, meaning inflammation of the epicondyle, is confusing). Either through a combination of repetitive injuries (the commoner scenario) there are many small tears of the muscle from bone (micro-trauma) or through one event, such as sudden awkward lifting, there will be pain on the outer side of the elbow. It appears that some people have a tendency to this hence they often develop symptoms on the other side as well.
The link with work is hotly debated. Large studies have shown that tennis elbow is no more common in manual than office workers. In most people it seems that at most the workplace makes a potentially or mildly symptomatic elbow more symptomatic. In a few cases particularly in a badly regulated workplace it seems that the work can lead to tennis elbow but this appears to be the exception not the norm.
What happens if nothing is done?
(This is referred to as the natural history i.e. what happens if Nature runs its own course.)
Many people's symptoms resolve either completely or at least sufficiently that they can live with them, especially if they avoid the activities that cause pain. Other people despite avoiding provocative activities or because they cannot such as at work, develop increasing symptoms which can be very marked and disabling.
Making the diagnosis
The Hand specialist who sees the patient will ask questions about their symptoms, when they started, how they progressed, what treatment (if any) they have had and other questions relevant to the problems. They will then examine the patient looking at their elbows, wrists and hands and in particular stressing the affected area. It is necessary to demonstrate some tenderness to confirm the site of the symptoms but this should not be too painful.
What test(s) might be performed?
Tests (also known medically as Investigations) include X-rays, scans, blood tests and particularly in the hand electrical tests (known as EMGs or Neurophysiology). These may be used to help make or confirm a diagnosis after a patient has described their symptoms and been examined.
In tennis elbow the diagnosis is usually obvious after listening to and examining a patient. If not the commonest test is an X-ray performed on the day of consultation. In more difficult cases an MRI scan may be performed. This is performed at a later date. An MRI scanner is usually a short tunnel which the patient's arms and top half of the body go into. Usually the arms are stretched out in a "superman" pose which is a little uncomfortable but generally well tolerated. Once in the tunnel a loud magnet is spun around and images of the bones and soft tissues created. Some people find the tunnel rather claustrophobic. If any patient doubts whether they would tolerate the scan they are best advised to visit the scanner department in advance. The films will be reported by a radiologist but also reviewed by the Hand specialist who will advise the patient accordingly.
If there is evidence of ulnar neuritis a neurophysiological assessment may be requested. This is also referred to as an electrical test. This is performed at a later date by a specialist (Neurophysiologist). Mild electric shocks are sent up and down the arm and the strength and speed of their conduction is measured. This gives a measure of nerve function. Like all tests it is not completely reliable so it can be normal although the patient has ulnar neuritis and it can be abnormal when the patient does not have ulnar neuritis. Your Hand specialist will interpret the results in the light of the previous description of symptoms and examination and advise you accordingly.
The other common possible causes of the symptoms are problems in the elbow such as arthritis.
What are the non-operative treatments?
Treatment should start with non-operative options. Patients are advised to reduce those activities that cause the pain and many of them will already have done that. Anti-inflammatory analgesics, such as Ibuprofen (Nurofen) and Diclofenac (Voltarol) can be helpful. These can be applied as a gel, massaging the area, or taken orally, assuming there is no history of indigestion. Tennis elbow splints worn in reverse can be of value. These can be purchased from sports shops. By gripping the muscles a little below the elbow they reduce some of the stress at the muscle attachment to the lateral epicondyle.
If these modalities fail then a steroid injection would usually be recommended. An injection is given of a long-acting steroid, such as Depomedrone or Triamcinolone, with some local anaesthetic into the joint at the bottom of the thumb. The body naturally produces steroids to help dampen down inflammation. This appears to be one of the actions at this site. Success cannot be guaranteed but in 70-80% of patients there is some significant benefit. How long this lasts is unpredictable. Some people only have a few weeks or months of benefit. Others may have years or even life-long benefit such that they do not require further treatment, although may still have some mild on-going symptoms. If one injection provides only short term benefit then it may well be repeated. Patients often ask how many injections can be given. There is no set rule about this. Typically, however, a second injection will work a little less well than the first (although this is not inevitable). By the time three injections have been given, if this is over a shortish period, i.e. less than 1 year, then it is unlikely the third injection will be successful and most surgeons would recommend an alternative approach. If, however, injections are only required infrequently, perhaps once every 2-3 years, then having a fourth or fifth injection would, in themselves, be a lot safer than having an operation, and if they give benefit this is reasonable. There are risks. The biggest risk is of failure. There are risks of some pain for a few days, although that is usually minimised by taking pain-killers, starting while the area is still numb from the local anaesthetic. In theory there is a risk of infection, but this seems very rare and has not occurred in our Practice in over 10 years. The main other risk is some thinning of the skin. This can present with some pallor and a little less bulk at the site and occasionally an increased tendency to bleeding if the area is knocked. This is more common with this injection than some other injections. If it does occur then that is a relative contra-indication to further injections, i.e. the patient's surgeon would probably decide not to go ahead with further injections because of the risks of further local damage.
What does the operation involve?
The operationis called a golfers elbow release or medial epicondylitis surgery.
If non-operative measures have failed to give adequate relief then surgery would be recommended. This is by no means essential and many patients cope long term with mild symptoms, particularly if it does not affect their day to day activities too much. Surgery is reasonably but by no means 100% reliable.
The operation is almost performed either under a general anaesthetic or, increasingly, under local anaesthetic,. A band, like a blood pressure cuff, is placed around the top of the arm. It is inflated (tightened) during the operation to reduce bleeding, which makes the operation easier and safer. It can be a little uncomfortable, but is almost always well tolerated for the 15-20 mins or so that it is inflated (this happens just before the surgeons starts the operation). Before that the arm is painted with an antiseptic with a pink dye in it. This is used to help minimise the risk of infection.
A 3-4cm incision is made on the inner aspect of the elbow. The abnormal tissue in the muscle is found and excised and may be sent to the Laboratory for analysis. The attachment of the muscle to the bone is released to take some of the strain off the muscle and prevent recurrent pain. The ulnar nerve is inspected and typically released. Sometimes this makes it ride forwards when the elbow is bent. This can cause further problems. It may therefore be necessary to remove a little of the bony prominence on the inner side of the elbow (medial epicondyle). This should give no structural problems but can make the elbow more tender in the post-operative period. The deep tissues are closed and the skin is closed normally with an absorbable suture. Either a soft dressing or a plaster cast is applied, depending on clinical findings and surgeon preference.
The total time in hospital is usually 3-4 hours.
What happens in the next few weeks?
The care of the hand in the post-operative period is very important in helping to ensure a good result. Initially the aims are comfort and elevation. These are met by keeping the hand up (elevated) especially in the first few days and by use of a long acting local anaesthetic (Bupivicaine). The local anaesthetic lasts at least 12 hours and sometimes 48 hours. Patients should start taking painkillers before the pain starts i.e. on return home and for at least 24 hours from there. This way most of our patients report little or any pain.
The bandage can be removed after 2-7 days, leaving a sticky dressing beneath. The patient or GP practice nurse can do this. If well healed at that stage then the wound can be left open (exposed). If in doubt it can be covered with a light dressing for a few more days. The patient is reviewed in clinic between 2-4 weeks following the operation. Typically dissolvable stitches are used so they should not require to be removed.
The hand can be used for normal activity after the first few days. Most patients can drive after a week or two. Most patients return to work in 3-4 weeks, but this varies with occupation; heavy manual work usually takes about 6 weeks. The wound should be massaged by the patient 3 times a day with a bland soft cream for 3 months once the wound is well healed (typically after 2 weeks). This reduces the scar sensitivity which can be a nuisance. If this is marked a Physio may be organised to help reduce the scar tenderness but this is rarely required. Patients should avoid pressing heavily on the scar for 3 months following the operation as this will be quite painful.
This is an operation where the race is won by the slowest (like the tortoise) and not the fastest. Patients are best advised to build their movements slowly. If they have been in plaster it will often take at least a further 2 weeks to regain full elbow movement but physiotherapy is not typically required. They should only undertake light activities with the operated arm until 6 weeks from surgery and then gradually build up heavier activities. Even at 3 months there is likely to be some continuous low grade discomfort. It will take at least 1 year and possibly 2 years for the optimal results to occur. Many patients wish to return to sporting activities and that is one of the aims of the operation. This should be gradual and, again, is better done too slowly rather than too quickly. It can probably start around the 6 week mark. For racquet sports the backhand only should be practiced for the next 1-2 weeks and gradually building up from there, bringing in forehand strokes but taking this slowly and being guided by any increase in pain.
What are the results of the operation?
Most patients have good results and in our experience a good 85-90% of patients are very satisfied, i.e.they have minimal or no pain, full movement in the elbow and a return to most if not all of their previous activities. Of the remaining 10-15% most of these have some benefit although probably have a little more continuing discomfort and restriction of activities. 1-2% of patients will be dissatisfied, either with almost no relief of their pain and rarely an increase in pain. The latter has never occurred with us over 10 years of experience but is a recognised complication of this operation.
Are there any risks?
All interventions in medicine have risks. In general the larger the operation the greater the risks. For golfers elbow surgery the risks include:
- The scar may be tender, in about 20% of patients. This usually improves with scar massage, over 3 months.
- Aching at the operation site for 3-6 months.
- Grip strength can also take some months to return to normal.
- Stiffness may occur in particular in the elbow. This is usually short-term and only infrequently requires physiotherapy.
- Numbness can occur around the scar but this rarely causes any functional problems. As the ulnar nerve is often decompressed this should help any numbness but with any nerve surgery there may be unpredictable responses and more nerve symptoms post-operatively although generally they settle.
- Wound infections occur in about 1% of cases. These usually quickly resolve with antibiotics.
- Chronic Regional Pain Syndrome "CRPS". This is a rare but serious complication, with no known cause or proven treatment. The nerves in the hand "over-react", causing swelling, pain, discolouration and stiffness, which improve very slowly.
- Any operation can have unforeseen consequences and leave a patient worse than before surgery.