Osteopathy Treatment Of Golfers Elbow
Golfers elbow, more technically called medial epicondylitis, is a similar type of condition to tennis elbow or lateral epicondylitis, but is less common. Since there is little or no inflammation present in these syndromes, they are known as tendinopathies, where degeneration of the tendon occurs and gives symptoms. Typical aggravating factors are racquet sports, golf and sports which involve throwing, although other sports people may be affected such as weight lifters, archers and cricket bowlers.
The forearm muscles, which flex and rotate the forearm, originate in tendon-like tissue at the medial epicondyle, the bony lump on the inside part of the elbow. Due to the lack of inflammation the term tendonitis is not correct and tendinopathy, an internal process of degeneration, is the preferred term. Any activity which pushes the lower arm outwards away from the body, into so-called valgus or knock elbow, puts extra force on the muscles of the flexor origin which are resisting the movement.
The flexor tendons are put under stress by activities which force the forearm outwards away from the body and these stresses occur as the wrist is cocked prior to throwing, in the early acceleration of the throw and in the golf swing from high backswing to just before the ball is hit. The dominant hand is affected in golfers and in tennis players those who impart a heavy topspin to the ball are more likely to suffer.Golfers elbow is not as common as tennis elbow but is the commonest cause of medial elbow pain with about half as many women affected as men. The third to fifth decades of life are the commonest periods for pain onset and 60% of golfers elbow occurs in the dominant hand. An acute onset of pain is reported in a third of patients, with the other two-thirds developing over a period of time.
Pain and ache over the front of the medial epicondyle is the typical symptom, worse with repeated flexion of the wrist and improved with resting. Shoulder, elbow, forearm or hand pain can occur, with weakness or pins and needles in the lower arm. Osteopathy examination includes the bony tendon insertions, the elbow joints and the muscles, with palpation of the funny bone area behind the elbow where the ulnar nerve lies. Nerve involvement can give weakness in the forearm muscles and sensory symptoms, so an exclusion neurological examination is performed by the osteo.
Most golfers elbow treatment is conservative, not surgical. Treatment involves activity modification, forearm or wrist splinting, anti-inflammatory drugs, steroid injections and osteopathy. Modification of the use of the arm is vital to prevent ongoing stimulation of the condition, so altering the mechanics of swinging the golf club or other sporting equipment is essential. Patient education continues with the identification of aggravating activities and postures and the patient is taught to avoid them.
Non-steroidal anti-inflammatory drugs are used by physios in the initial acute phase to reduce pain and inflammation along with avoiding painful movements, use of ice, gentle stretches, friction massage and ultrasound. As the problem settles and becomes sub acute the aims change to improving flexibility by stretching, increasing strength and normal activities. A forearm brace may also be used or a wrist brace to rest the wrist muscles. Once the problem is chronic the programme continues with reduced use of the splint and re-introduction of sporting activities.
Corticosteroid injections are commonly used for treatment of longer term medial epicondylitis but are more useful early on in the management of golfers elbow to relieve pain. Laser and shockwave therapy have no good evidence for usefulness. Surgery is only considered once conservative osteopathy has failed. Surgery is used to debride the abnormal tissue from the affected area and in the cases of nerve involvement to move the ulnar nerve from its groove round to the front of the elbow.
Correction of sporting technique, such as the golf swing, is best achieved by engaging a professional instructor who can also advise on stretches, fitness work and muscle strengthening. Athletes should warm up well before sport and stretch effectively afterwards, choosing good technique and selection of appropriate equipment. Doctors and osteotherapists may need to monitor patients, especially athletes, very carefully as they tend to continue to perform through the pain.
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