Alternative medicines

Posts Tagged ‘pain management’

Golfer’s elbow (medial epicondylitis) is not confined to golfers, but occurs in many sportsmen and women, with racquet sports the most common causes. Other sports where golfer’s elbow occurs are in bowlers in cricket, archers and weightlifters. This and the more common tennis elbow are tendinopathies, overuse syndromes where there is no significant inflammation but a pathological alteration in the body of the tendon at the painful site.

The muscles which flex and rotate the forearm originate over the medial epicondyle, the bony prominence on the inside of the elbow, with the tendon anchored into the bone by the tendinous insertion. The pain occurs close to this and may be due to a degenerative process occurring in the tendon, as little inflammation has been noted in these cases.

High stresses occur in the cocking phase of a throw and during the subsequent acceleration, and in the golf swing from high backswing down to near the ball strike. Golfers are more likely to have their dominant hand affected and tennis players who use heavy topspin in their forehands are also more at risk.

Golfer’s elbow is the most common cause of pain over the inside of the elbow and less common than tennis elbow. Twice as many men are affected as women, with people being affected initially mostly in their twenties to their forties. Golfer’s elbow presents in the dominant hand in 60% of occurrences, with 30% of sufferers reporting a sudden and painful onset, the remainder having a slow onset.

Patients complain of aching pain over the front of the inner epicondyle, worse with repeated wrist flexion and better with rest. Pain can occur in the shoulder, elbow, forearm or hand, with weakness in the lower arm and hand also. The physiotherapist will examine the bony areas and joints of the elbow, check the muscles and their tendinous insertions. The physio palpates the ulnar nerve in the groove behind the elbow, called the “funny bone” when it’s hit. The nerve can give pins and needles or weakness in the forearm and a neurological examination excludes other causes of pain or weakness.

Conservative, non-surgical, treatment is the mainstay of management. This includes physiotherapy, anti-inflammatory drugs, wrist splints and steroid injections. Patient education is important and activity modification is the first line of treatment, reducing the frequency of aggravating episodes. Altering the mechanics of the golf swing or other activity is vital if the area is to be allowed to settle. The patient avoids certain activities with the affected muscles and avoids leaning on the elbow.

In the acute phase of golfer’s elbow the physiotherapist’s aim is to reduce any pain and inflammation using ice treatment, stretching gently, deep frictions, ultrasound and anti-inflammatory medication. Progression into the sub acute phase changes treatment to increasing flexibility, strength and returning to normal activities in a paced manner. Counterforce forearm bracing can help realign the tendon stresses, or a wrist brace can give the muscles a rest. For a chronic syndrome the treatment is similar with reducing splint use and returning to sporting activities.

Doctors inject corticosteroid medication into the sites of chronic golfer’s elbow but this treatment appears to be more useful in the earlier, acute cases. Other therapies, such as shockwave or laser, have been used but do not seem to be effective. Once physio has been attempted for some time without improvement then a surgical approach may be considered, cutting out the abnormal tissue from the tendon. The ulnar nerve can be transposed around to the front of the joint from its position in the groove posteriorly.

Advice from a professional instructor is well worthwhile as they can instruct on technique of the golf swing, aerobic fitness, muscle strength work and flexibility. Warming up prior to activity and stretching afterwards, with good sporting technique and sound choice of equipment are the basic requirements. Monitoring of patients by the physiotherapist, especially if they are sports people, may be essential to avoid overdoing and training or performing through pain.