Epitrocleitis (golfer’s elbow)

What is epitrocleitis?

Epitrocleitis or golfer’s elbow is one of the most common causes of pain in the medial aspect of the elbow. It is characterized by extending from the elbow to the wrist on the forearm side. This pain is due to an injury to the tendons that are responsible for flexing the wrist towards the palm of the hand.

Unlike the famous “tennis elbow”, it is much less frequent. Although it usually appears in athletes who play golf, tennis or javelin, it can also occur in professionals who perform manual labor, such as mechanics or carpenters, who perform repetitive movements of the forearm, wrist and hand.

It is an injury that usually damages the dominant limb, appears around 40-50 years of age and affects men and women equally.

Epitrochleitis is characterized by pain extending from the elbow to the wrist.

Prognosis of the disease

Normally epitrochleitis is an easily treatable injury and the patient recovers well with conservative treatment, so the prognosis is not particularly serious. Only in some cases where this treatment does not work will surgery be recommended.

Symptoms of epitrochleitis

Golfer’s elbow or epitrocleitis is also called pronator-flexor syndrome. It is characterized by causing the patient pain on the inside of the elbow, over the epitrochlea, that is, the bony prominence on the inner side of the end of the humerus. It is a pain that is related to the repetitive use or overuse of the muscle insertion at that point.

Such pain is worsened by flexing the wrist and pronation of the forearm against resistance. Sometimes, in addition, the pain can extend to the forearm. When the pain becomes chronic, weakness may be added when grasping objects.

In patients who are athletes the pain may manifest itself in the acceleration phase of the throw, i.e. when serving in tennis or throwing the javelin.

Medical tests for epitrochleitis

The diagnosis of epitrochleitis is based on clinical examination. X-rays are not usually necessary, but the orthopedic or sports medicine specialist may decide to do them to make sure that the bones of the elbow are normal and not spiky, and to look for calcium deposits in the injured tendons.

What is sometimes performed is an MRI and also an ultrasound. The latter can help detect hypoechoic areas, which means that the tendon has degenerated, affecting the collagenous tissue. This will allow to compare it with the other arm and select the best treatment for the patient.

What are the causes of epitrochleitis?

The epitrochlea (bony protuberance at the end of the humerus) is the origin of the muscle group responsible for flexing the wrist and fingers, as well as pronating the forearm. It is in this area where the injury occurs.

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The main cause is the overuse or repetition of movements in the area. Thereafter there is an inflammatory process that evolves into tendon degeneration. This is characterized because the patient suffers micro ruptures in the tendons and it is repaired in a failed way. If the injury evolves, there will be degeneration, not inflammation.

Can it be prevented?

Epitrochleitis can be prevented, basically, by strengthening the muscles, stretching the flexor muscles of the forearm and with technical adaptation and appropriate sports equipment for each sport. As the patient perfects the technique he/she will avoid relapses. A proper warm-up should also be done before engaging in sports or manual activities. Once the exercise is finished, stretching should also be done to maintain flexibility.

In the case of patients who play golf, it is important to have a specialist check the hitting technique and grip, as well as the type of golf clubs used. If they play tennis, the same applies: analyze the hitting technique, the size of the racquet, the tension of the strings, etc.

Any prevention is good, and will be based on avoiding repetitive movements, preserving the integrity of the collagen as much as possible and avoiding repetitive microtrauma.

Treatments for epitrochleitis

The main treatment for epitrochleitis is non-surgical. It is aimed at relieving pain and inflammation, as well as allowing the patient to return to his or her activities. Although treatment is effective in almost 90% of patients with this injury, there is a 5-15% recurrence of symptoms, usually due to incomplete rehabilitation or failure to comply with the recommended preventive measures, or because the damage is very advanced and biological therapies for tissue regeneration are necessary.

The treatment of choice, therefore, will be conservative. It basically consists of modifying the activities or avoiding those that produce the symptoms. In some cases it will be necessary to combine it with anti-inflammatory medication, kinesiotherapy and application of local ice after the activity. In other occasions it will be necessary an elbow orthosis, which will help to diminish the pain.

Corticosteroids can also be useful to alleviate pain but should only be administered if there is a flare-up and when other conservative techniques do not work.

Other therapies used to regenerate the tendon may include extracorporeal shock waves, percutaneous intratissue electrolysis (PIE), botulinum toxin infiltration, ultrasound-guided infiltration of platelet-rich plasma or low-intensity laser therapy.

If all the above-mentioned measures fail after some time of their application, surgical intervention may be considered. All of them will aim at releasing the muscular origin and a resection of the affected tissue. The success rate is high but there may be complications, such as ulnar nerve injury, especially with minimally invasive techniques such as arthroscopy.

Which specialist treats it?

The specialist in charge of studying and treating epitrochleitis is the traumatologist. In particular, a better diagnosis can be made by one who specializes in the elbow joint. The injury may also be treated by a sports physician.