Golf Injuries

Understanding Elbow Pain: How to Make Sense of Elbow Pain

I would like to recap what we’ve covered so far in the introduction and part one of the series:

  • Introduction to a Four Part Series:
    • Overview of the Understanding Elbow Pain Series
    • Basic anatomy and relevant anatomical terms
  • How the Golf Swing Stresses the Elbow:
    • Biomechanics of the elbow, forearm, and wrist during the golf swing
    • Variations between different golfers
    • Common swing faults and their impact on the elbow and wrist
    • Two mechanisms to developing elbow pain
      • Traumatic stress
      • Repetitive over-use stress

I highly suggest backtracking and checking out those articles if you have not already. There is a lot of useful information in them and will help you to understand the next parts of the series.

 

How to Make Sense of Elbow Pain

This article will discuss the common presentation of a golfer with elbow pain, different common diagnosis of elbow pain I see when treating golfers, and different stages of tendinopathy related elbow pain.

For the purposes of this article, I will break down golf-related elbow pain into two specific categories: medial elbow pain and lateral elbow pain.

Medial Elbow Pain/ Medial Epicondylitis

As discussed previously, medial elbow pain is a common complaint of golfers that I work with. Although it is less common than lateral elbow pain, medial elbow pain can significantly impact a golfers ability to consistently strike the ball.

Due to the relatively complex nature of the anatomy of the inner elbow, there are a few different structures or pathologies that can occur. The far most common for golfers, however, is a tendinopathy of the common flexor tendon also known as medial epicondylitis or “golfers elbow.”

Presentation

The hallmark signs of medial elbow pain in golfers that would make a clinician suspect medial epicondylitis are:

  • Subjective history of medial elbow pain, particularly with explosive movements such as the golf swing
  • Most commonly occurs in the trail side elbow (right elbow for a right-handed golfer)
  • Tenderness or pain to palpation of the medial epicondyle and common flexor tendon
  • Painful resisted wrist flexion and forearm pronation
  • Positive or provocative special tests such as the Golfer’s Elbow Test

 

Credit: The Joint and Spine Institute

Mechanism of Injury

Traumatic: The mechanism for medial epicondylitis is typically traumatic in nature. This can happen when striking the ground fat, hitting a root, or digging the club into the sand. These types of strikes can cause a sudden deceleration of the club, causing increased traction-based loading at the medial epicondyle/common flexor tendon.

I like to think of it this way: the energy from the club is abruptly stopped by a foreign object and travels up the shaft of the club. The energy will first encounter the wrist and hands, which are typically at a pretty “strong position” at impact. The trail elbow, however, is at a more vulnerable position and so the it takes the brunt of the energy.

Traumatic Overuse: This typically occurs from hitting golf balls off a hard surface repeatedly, such as a driving range mat. This is different than a strictly traumatic onset medial epicondylitis because it typically does not occur on one specific swing. Often, repeated microtraumas over the course of a practice session or days to weeks will lead to the development of pain.

It is important to to distinguish between a strictly traumatic injury and traumatic overuse injury because it may affect the severity of the injury, the treatment course, and the timeline for return to playing golf.

Other Potential Causes of Medial Elbow Pain (Less Common)

  • Referred pain from the cervical spine
  • Ulnar neuropathy or cubital tunnel syndrome
  • UCL injury– not very common at all in golfers
  • Medial epicondyle growth plate stress reaction/stress fracture
    • This will only occur in younger golfers whose growth plates are still open (aka still growing)
    • If you are a junior golfer with elbow pain on the medial epicondyle, I definitely suggest seeing a doctor for medical advice

This is not an extensive list because I want to keep this super simple.

**Bottom line– do not use this article to self diagnose. I always recommend seeking help from a healthcare professional (doctor, physical therapist, etc) to diagnose injuries.**

 

Lateral Elbow Pain/Lateral Epicondylitis

Lateral elbow pain is five times more common in golfers than medial elbow pain and typically occurs in the lead side elbow. Lateral elbow pain can rob a golfer of distance, power, feel, touch, and make the playing experience enjoyable.

The majority of golfers that I see present with tendinopathy of the common extensor tendon. This is typically referred to as lateral epicondylitis or “tennis elbow.” 

Presentation

The hallmark signs of lateral elbow pain in golfers that would make a clinician suspect lateral epicondylitis are:

Credit: Physiopedia
  • Subjective history of lateral elbow pain, particularly with explosive movements such as the golf swing
  • Most commonly occurs in the lead side elbow (left elbow for a right-handed golfer)
  • Tenderness or pain to palpation of the lateral epicondyle and common extensor tendon
  • Painful resisted wrist extension
  • Positive or provocative special tests such as the Mills, Maudsley and Cozen’s Tests

 

 

 

Mechanism of Injury

The most common mechanism for developing lateral epicondylitis in golfers is repetitive over-use.

Although one golf swing may not be excessively stressful, when repeated thousands of times it may surpass the threshold of what our body can handle. I’ve often found that golfers experience repetitive over-use injuries for two reasons:

  • Taking way too many golf swings (Cumulative Load Theory)
  • Sudden spike in swing volume (Acute-Chronic Workload Theory)

Managing practice and play over the course of a single day, month, season, and year seems to be the best way to avoid developing an overuse injury.

Once pain develops, it is important to closely analyze swing volume and decrease the painful stimulus. This may mean taking a few days to weeks off from golf, or simply not hitting balls until your elbow is in serious pain.

 

Other Potential Causes of Lateral Elbow Pain

  • Referred pain from cervical spine
  • Radial head fracture– very severe pain, usually from a traumatic fall
  • Radial nerve entrapment
  • OCD Lesion
  • Growth plate stress reaction/fracture
    • Will only occur in younger children who are still growing

Again, not an extensive list because I want to keep this super simple.

**Bottom line– do not use this article to self diagnose. I always recommend seeking help from a healthcare professional (doctor, physical therapist, etc) to diagnose injuries.**

 

What is a Tendinopathy?

I have been using the terms “medial epicondylitis”, “lateral epicondylitis”, and “tendinopathy” frequently in this series. I want to go over how current literature defines tendinopathy and what this means for golfers.

The major clinical features of tendinopathy are:

  • Tenderness of the affected part of the tendon
  • Pain with tendon loading (stressing the tendon)
  • Palpable nodule thickening of the tendon (occasionally)

In 2010, Jill Cook et al. came out with a hallmark paper on tendinopathy that presented a new model of explaining overuse tendon injuries. Cook et al. describe tendinopathy as a continuum with three stages. The three stages are:

Credit: Jill Cook et al. BJSM 2010

1. Reactive Tendinopathy

  • Acute overload
    • Occurs with acute tensile or compressive tendon loading surpassing the capacity of the tendon
  • Non-inflammatory proliferative process
  • Short-term thickening of tendon to distribute load over a larger surface area

Think of the reactive tendinopathy as your body’s initial response to a threat. It makes quick, short-term solutions to the problem at hand. In the reactive phase, the tendon has the possibility of returning to normal if the overload is properly reduced and adequate rest before re-introducing the stress is allowed.

2. Tendon Dysrepair

  • Attempted healing of the tendon
  • Increased cellular activity in the tendon
  • Disorganized collagen formation

While your body is attempting to repair the ‘damaged’ tendon, cells rush into the area to make the repairs. This is the equivalent of a brick-layer trying to fix a wall as fast as possible. The brick-layer is not necessarily concerned with how the bricks look and if they’re placed perfectly; he just wants to fix the wall as fast as possible. The body reacts the same way which leads to collagen fibers being laid down quickly and haphazardly.

3. Degenerative Tendinopathy

The authors stress that people with a tendinopathy can fluctuate between stages and various areas of the same tendon may be in different stages at the same time.

  • Areas of cellular death
  • Other types of cells popular the tendon, weakening the tendon
  • Little chance of reversibility back to a normal tendon in this phase

This is the most progressed phase of tendinopathy. Ideally, golfers seek help before it gets to this point as it becomes increasingly unlikely that the tendon returns to its original strength and stiffness once it progresses this fair.

 

What is the Cause of Pain in Tendinopathy

The short answer is: we don’t know what exactly causes pain associated with a tendinopathy.

The interesting thing is when we do diagnostic imaging of tendons, some people have significant changes to the tendon but have no pain. Some people have less severe tendinopathy according to imaging, but have serious pain that affects their day to day life. To make it more confusing, a once painful tendon that is no longer painful often appears identical on imaging.

The bottom line is we still don’t know exactly why tendons become painful. The current medical research suggests that it may be a combination of the cellular processes associated with tendinopathy and more central processes controlled by the nervous system. Other factors such as periods of high stress, emotional and mental state, and social factors can also contribute to pain.

Overall, there are many factors that can contribute to pain experienced from tendinopathy. It is important for golfers to realize the process of a tendinopathy in order to seek medical help early in the process before it progresses to later stages. The sooner a tendinopathy can be diagnosed and treated, the better the outcome.

Simplifying Tendinopathy

Let me make this a little easier to digest:

Tendinopathy occurs from microtrauma to a tendon. This can be from one specific swing or from many repeated swings over time. The tendon naturally tries to repair itself, but it does so quickly and often does not do a fantastic job of restoring the tendon to its normal state immediately. If the stimulus that caused the initial insult continues, there many additional trauma to the tendon and it may progress through the various stages above. The final stage of tendinopathy involves areas of cellular death in the tendon, making it more unlikely that the tendon can repair itself. We aren’t sure why tendons become painful but it seems to be multi-factorial.

It is crucial that golfers are aware that tendinopathy can be progressive, so pushing through significant pain is not always a good strategy to combat it. The longer that the tendon continues to get irritated, the harder it will become to get back to ‘normal.’

Where Do We Go From Here?

The next article will cover how to manage a tendinopathy. This will include treatment techniques that are based in science. I will also discuss how and when to return to golf to minimize the risk of having recurring, nagging elbow pain. Stay tuned!