Epicondylitis

NOTE: This page refers to “Golfer’s Elbow” or medial epicondylitis and “Tennis Elbow” or lateral epicondylitis.

What is “Golfer’s Elbow”?

Golfer’s Elbow is the common name for a muscle, tendon, or fascial pain occurring on the inside of your elbow. It’s actually a misnomer because the name suggests that it only happens to people who golf. The truth is that it can happen to anyone who overuses the muscles on the inside of their forearm, and the proper term is “medial epicondylitis”.

golfer's elbowThese muscles are the wrist and finger flexors, and they attach to a common tendon that, in turn, attaches to the bony bump on the inside elbow called the medial epicondyle. Pain from golfer’s elbow could be a muscle strain or sprain, microtearing of the muscle or common flexor tendon, a build-up of scar tissue or dysfunctional scarring, or simple muscle overwork (chronically tight flexor muscles), but they all result in inflammation at or near the junction of the common flexor tendon and the medial epicondyle.

NOTE: If you experience either golfer’s or tennis elbow, it is a good idea to have a physician evaluate it for diagnosis before seeking treatment. Elbow pain may have more involved, such as bone spurring, a pinched ulnar nerve, or tendonosis, which is a degeneration of the tendon at the cellular level. There may be an inflammation of the common flexor and extensor tendons, in which case, the doctor would call it tendonitis.

Sound Familiar…but Different? What is “Tennis Elbow”?

Does this sound like a pain you’re experiencing, except that yours is happening on the outside of your elbow

golfer's elbow

Top – golfer’s elbow
Bottom – tennis elbow

rather than the inside? If so, then that is called “lateral epicondylitis” and referred to as “tennis elbow”. It may be confusing to add that a golfer can be diagnosed with tennis elbow, just as a tennis player can have golfer’s elbow. Best not to get hung up on the common names of these.

Anatomy

To better understand epicondylitis, let’s have a look at the anatomy of inside and outside of the forearm and elbow and the muscles involved there.

First, as mentioned before, epicondylitis is typically an inflammation of the common flexor or extensor tendon. Muscles are the contractile tissues of the complex. In order for us to close our fingers or fists or bend our wrists downward, we have a group of muscles called wrist and finger flexors. Any arm or finger movement for gripping, grasping, holding, or flexing or turning the wrist thumb-down, will use muscles of the forearm flexor group. Doing the opposite, that is opening a fist or bending a wrist back will use the extensor group. Both groups are called into service whenever an isometric contraction is called for, such as holding a wrist steady as we pick something up or use a hand fan, swinging a weight, etc.

At the far end of the flexors, tendons attach to the bony digits of our fingers and thumbs, or to points at or near the wrist on the radius, the bone on the thumb side of the forearm. These tendons are continuous with muscles of the flexor group. The muscle bellies then stretch between those tendons and the tendons of their upper attachment. As the flexors near the elbow, they join together to the thick common flexor tendon. This tendon, in turn, attaches at the bony bump in your inside elbow, the medial epicondyle, which is one side of the knobby end of the upper arm bone, the humerus.

Extensors also attach to our fingers and thumbs, and also to points at or near the wrist on the radius, but on the back of the hand and arm. The extensors join together into what is referred to as the common extensor tendon near the elbow. And the tendon attaches to the outside bony bump at your elbow, the lateral epicondyle. Inflammation of that tendon is where the term epicondylitis comes from.

Tendons

Now, a little more focus on tendons. So, between the bones and continuous with muscles are tendons. Tendons do stretch a little and act as shock absorbers for the muscles when taking a strain. But they’re made up of a different material than muscle and, while elastic to some degree, cannot willfully contract. Current science says that tendons have relatively little innervation compared with muscles, nor do they have a good blood supply. That’s why a torn tendon takes an extraordinarily long time to heal — if it ever can. However, tendons do have many cells living in them and they do all sorts of work in there.

When a muscle overworks, it puts a lot of tension on the tendon. Too much strain can cause microtearing of the tendon tissue. Commonly, tearing most often occurs either at the muscle-tendon junction or at the tendon-bone junction. Some cells that live in the tendon are responsible for repairing the area they’re lodged in. They throw down a substance called collagen and a glue matrix to patch up tears in the tissue. However, this substance differs slightly from the original tissue and it really is just thrown down.

I like to think of it as the cell being a person on a truck loaded with chopped up firewood, and their job is to take the firewood off the truck and put it on the ground. If there was another person on the ground neatly stacking the firewood, all would be well. But that doesn’t happen with tissue repair. The cell just tosses the firewood (collagen) off the truck into a big pile and the individual pieces lay in a helter-skelter fashion. That gives the scar its unusual appearance, and very often a raised, bumpy, uneven surface.

The collagen matrix sticks to everything it lands on and reduces the elasticity of the tendon wherever it comes in contact with it. When the tendon then stretches again, it rips the scar tissue and possibly the tendon tissue, too, and the whole process begins again. Chances are that every time you feel pain in that elbow when you’re doing something, a little more microtearing is taking place.

The “itis”

Remember, this is about medial eplicondyl-itis. Any condition where tissue becomes inflamed has the suffix “itis” attached to it in our language. Inflammation happens when original tissue damage takes place and when scar tissue is torn. Inflammation is the body’s way of sending repair cells to damaged tissue.

tendon tears

microtearing

However, constant tearing of the tissue results in constant inflammation, and that’s not a good thing. Eventually, the body may give up trying to repair the damage. If this happens, eventually the inflammation will go down and tissue degeneration starts taking place. Doctors call this condition of degeneration without inflammation tendonosis.

Cause of Epicondylitis

More often than not, a person develops golfer’s or tennis elbow by overusing the forearm muscles.

“Golfer’s elbow” is so named because the downward swing in golf uses those muscles, and it uses them a lot (repetitive motion/repetitive use). A worse case may occur when, at the bottom of the downward swing, the club hits the ground instead of the ball and comes to a sudden stop when the forearm muscles are still contracted and arms have considerable inertia behind them.

“Tennis elbow” gets its name from the backhand swing in tennis, especially from the sudden loading of the extensors when the racket meets the ball.

But golf and tennis are not the only way to acquire an injury to these tendons. You can get them from throwing a ball, rock climbing, typing on a keyboard, constantly picking up objects, working in the garden, holding onto bicycle handlebars, playing the drums, using most hand tools, etc. There are many ways to overuse the forearm, but they all have at least one of these (often, more) in common:

  • Constant loading
  • Sudden loading unexercised muscle
  • Sudden overloading
  • Repetitive use
  • Overstretching
  • Dysfunctional muscles in the kinetic chain

As indicated earlier, both golfer’s and tennis elbow can also be caused by tendon-osis, a cellular degeneration of tendon tissue.

Symptoms of Golfer’s Elbow

Pain at or near the medial epicondyle is the most obvious symptom of this condition. Pain begins with flexion of fingers or wrist, and worsens when flexion tension increases. Pain may be a constant dull ache or a sudden, sharp pain. And spontaneous pain usually diminishes or disappears when the finger and wrist flexor muscles are relaxed and starts again when finger and wrist flexors are activated.

Symptoms of Tennis Elbow

Pain at or near the lateral epicondyle or in the upper extensor muscle bellies betray this condition. Similarly, the pronator teres muscle attaches at the lateral epicondyle as well, and the condition may indicate extensors or pronators. An assessment will need to be done to determine which if not both. As with Golfer’s elbow, pain usually stops as soon as a muscle is relaxed, but starts again with loading. Pain may not occur at all angles of wrist or finger extension or unless pronation is resisted. Also, the shoulder may need to be extended in order to obtain the most significant pain from Tennis elbow.