Medial Epicondyle Injection for Golfer’s Elbow

Indications and Clinical Considerations

Golfer’s elbow (also known as medial epicondylitis ) is caused by repetitive microtrauma to the flexor tendons of the forearm in a manner analogous to tennis elbow. The pathophysiology of golfer’s elbow is initially caused by microtearing at the origin of the pronator teres, flexor carpi radialis and flexor carpi ulnaris, and palmaris longus ( Fig. 62.1 ). Secondary inflammation may occur, which can become chronic as a result of continued overuse or misuse of the flexors of the forearm. Coexistent bursitis, arthritis, and gout may also perpetuate the pain and disability of golfer’s elbow.

FIG. 62.1, Golfer’s elbow. A , Coronal T2 MRI of a patient’s elbow with medial epicondylitis showing inflammation at the medial epicondyle, the origin of the common flexor tendon ( white arrow ) with an intact UCL ( black arrow ). This is in contrast with the image on the right ( B ), which is a coronal T2 MRI scan of a patient with a UCL tear that shows a proximal tear of the UCL from its origin on the medial epicondyle ( red arrow ). MRI, magnetic resonance imaging; UCL, ulnar collateral ligament.

Golfer’s elbow occurs in patients engaged in repetitive flexion activities that include throwing baseballs, carrying heavy suitcases, and driving golf balls. These activities have in common the repetitive flexion of the wrist and strain on the flexor tendons from excessive weight or sudden arrested motion. Interestingly, many of the activities that can cause tennis elbow can also cause golfer’s elbow.

The pain of golfer’s elbow is localized to the region of the medial epicondyle. It is constant and is made worse with active contraction of the wrist. Patients note the inability to hold a coffee cup or hammer. Sleep disturbance is common. On physical examination, there is tenderness along the flexor tendons at or just below the medial epicondyle. Many patients with golfer’s elbow exhibit a bandlike thickening within the affected flexor tendons. Elbow range of motion is normal. Grip strength on the affected side is diminished. Patients with golfer’s elbow demonstrate a positive golfer’s elbow test. The test is performed by stabilizing the patient’s forearm and then having the patient actively flex the wrist. The examiner then attempts to force the wrist into extension ( Fig. 62.2 ). Sudden, severe pain is highly suggestive of golfer’s elbow.

FIG. 62.2, Patients with golfer’s elbow will exhibit a positive golfer’s elbow test.

Occasionally C6-C7 radiculopathy can mimic golfer’s elbow. The patient with cervical radiculopathy usually has neck pain and proximal upper extremity pain in addition to symptoms below the elbow. Electromyography helps distinguish radiculopathy from golfer’s elbow. Plain radiographs are indicated in all patients with golfer’s elbow to rule out joint mice and other occult bony disease. On the basis of the patient’s clinical presentation, additional testing may be indicated, including complete blood cell count, uric acid, sedimentation rate, and antinuclear antibody testing. Magnetic resonance imaging and ultrasound imaging of the elbow are indicated to determine joint instability and to help confirm the diagnosis. The injection technique described later serves as both a diagnostic and a therapeutic maneuver.

Clinically Relevant Anatomy

The most common nidus of pain from golfer’s elbow is the bony origin of the flexor tendon of the flexor carpi radialis and the humeral heads of the flexor carpi ulnaris and pronator teres at the medial epicondyle of the humerus ( Figs. 62.3 to 62.5 ). Although it is less common, golfer’s elbow pain can also originate from the ulnar head of the flexor carpi ulnaris at the medial aspect of the olecranon process. As mentioned earlier, bursitis may accompany golfer’s elbow. The olecranon bursa lies in the posterior aspect of the elbow joint and also may become inflamed as a result of direct trauma or overuse of the joint. Other bursae susceptible to the development of bursitis exist between the insertion of the biceps and the head of the radius, as well as in the antecubital and cubital area.