Golfer’s elbow is caused by repetitive twisting motion of the wrist, which affects the forearm muscles, like in this golf swing. — AFP
In young children and toddlers, nursemaid’s elbow is a common injury that occurs when a child is yanked too hard by his hand or wrist.
It may happen when someone lifts a child up by one arm, for example, when trying to carry the child over a curb or high step.
But generally, out of all the joints in the human body, the elbow is probably one of the least prone to wear-and-tear damage.
Still, you often hear adults saying they have tennis or golfer’s elbow, despite not playing these sports.
“Like the terms imply, we see patients who play these two games, but it can also affect those who don’t play these games.
“The injuries are similar, but occur in different locations that involve the forearm muscle,” says consultant orthopaedic surgeon Datuk Dr Mohd Asri Abd Ghapar.
The elbow joint is where three bones in the arm meet: the upper arm bone (humerus) and the two forearm bones (radius and ulna).
It is a combination of a hinge and pivot joint.
The hinge part of the joint lets the arm bend and straighten; the pivot part lets the lower arm twist and rotate.
It acts in tandem with the rest of the upper limb when we want to execute a certain activity.
“So, it’s not just the elbow that is doing everything.
“When you open the door knob or want to grip something, you will use the hand, but the strength comes from the forearm muscles, which is attached to the elbow.
“When you throw something forcefully, the strength comes from the forearm and shoulder muscles, which can also affect the elbow and cause pain,” explains Dr Mohd Asri.
Inflamed tendons
An illustration of tennis elbow (known medically as lateral epicondylitis) showing inflammation of a tendon at the outer elbow. — 123rf.com
Tennis elbow refers to pain on the outer or lateral side of the elbow and is medically termed lateral epicondylitis.
Symptoms include weak grip strength and a pain or burning sensation on the outer part of the elbow.
Usually, the symptoms get worse when you use your forearm in activities like holding a racquet, turning a wrench, flushing the toilet or shaking hands.
Golfer’s elbow is pain on the inner or medial side of the elbow and is referred to as medial epicondylitis.
Golfer’s elbow involves the forearm muscles that stretch from the wrist to the “funny bone” area of the elbow near the inner bump.
These muscles are responsible for wrist flexion (or the twisting motion of the wrist), which explains its connection to golf.
Both conditions are a form of tendonitis, a result of inflammation of the elbow joint from overuse and wearing down of the tendons in the forearm.
“But don’t be surprised if the golfers get tennis elbow and vice versa!” says Dr Mohd Asri.
“A lot of people think tennis players end up with tennis elbow as they use a lot of backhand shots, but this is not necessarily true.
“When they’re hitting the ball, the force is transmitted from the racquet to the arm, so the arm has to be strong.
“The elbow gets the impact of hitting the ball.
“If you’re late in striking the ball (and use a forehand stroke instead), the force is transmitted to the inner side of the forearm, hence tennis players get golfer’s elbow; there is pain and inflammation.”
However, golfers don’t tend to get tennis elbow so much from playing golf itself, but more so from carrying the heavy golf bags.
Activities that require repetitive gripping motions, such as throwing, rock climbing or heavy weight training, can also lead to golfer’s elbow.
Many affected people tend to do work that involves knocking or hammering, and using manual screwdrivers.
The torquing motion of turning and twisting the forearm in an awkward position can irritate the tendon.
“Injuries can also be due to repetitive or improper tool usage or sizing of the equipment used, e.g. the size of the handle of the hammer or the racquet size.
“Even housewives or chefs who cook a lot and have to lift heavy woks can get tennis elbow.
“If the injury is in the tendon attaching to the bone, it’s considered as tendonitis.
“Sometimes, the injury is at the part of the muscle just before it reaches the tendon.
“The pain will then radiate down to the lower part of the elbow,” he says.
Right at the centre of the elbow is the part of the ulna bone on which we usually rest our arm on a chair or table.
When you knock this bumpy notch called the olecranon process, you might get a funny feeling.
Dr Mohd Asri adds: “The ulnar nerve runs in the inner part, so you might get an electrical shock-like feeling when you hit it.
“Normally, this is an impact injury, not a repetitive one.”
Conservative route
Activities that require repetitive gripping motions such as lifting heavy weights can also lead to golfer's elbow. — Photos: Filepic
Most exercise enthusiasts would warm up and do mini stretches for their lower limbs before beginning their activity.
“As you age, the joints start becoming stiff, so try to do a little bit of upper limb warm-up as well, even if you’re only running,” advises Dr Mohd Asri.
Joint stiffness may be mild and only impact your mobility for a brief period of time, especially when you wake up in the morning or after sitting for extended periods of time.
If the stiffness is not accompanied by pain or inflammation, and is not due to conditions such as arthritis, stretching always helps reduce the stiffness.
“I’ve also seen patients who use tablets, and instead of placing it on a table, they grip the tablet with one hand to stabilise it.
“They use it for long periods and end up getting stiffness and pain in the inner elbow,” he says.
To treat these conditions, conservative treatment is best.
In most instances, patients would have undergone a period of self-
treatment as there is a plethora of information available on the Internet.
Dr Mohd Asri says: “It’s not the wrong thing to do as the information is mostly correct.
“Depending on the severity of the condition, patients would have rested or taken over-the-counter or leftover medication, applied ice, gel or ointment at the pain site, etc.
“If the pain settles in a week, they can resume their normal activities.
“But if it recurs, then they need to see a doctor – the general practitioner (GP) can treat the problem in the early stages.
“When they come to us, it’s usually quite severe already.
“We assess the case and ask what difficulties they are having, e.g. is opening a jar difficult, etc.
“Then we refer them to a physiotherapist to gradually improve function.”
Treatment options include a few sessions of simple exercises, ultrasound for pain management, and laser or shockwave therapy to reduce pain.
“The magic number is always three months to completely recover because we don’t want them to return to activity too soon and risk a recurrence.
“We have to respect the body’s time frame for healing.
“If they resume activities too early, the healing is not complete and they will most likely suffer the same problem again,” he points out, adding that these elbow conditions mostly affect men and women above the age of 40.
The patient is expected to regain strength during this time of rest, but if they still don’t get better after three months, then the doctor might recommend other treatments.
Effective, but eventually detrimental
For some recurring cases, part of the treatment is cortisone infiltration or injection, which is an effective treatment for inflammatory reaction anywhere in the body.
Those who cook and stir or lift heavy woks are also prone to tennis elbow.
It is commonly injected into joints such as the ankle, elbow, hip, knee, shoulder, spine or wrist.
Even the small joints in your hands or feet might benefit from cortisone shots.
The injections usually contain a corticosteroid medication and a local anaesthetic.
A single injection is fine, but there are patients who go “doctor hopping” and ask for more jabs to numb the pain.
One too many shots can cause softening or tearing of the tendon.
Dr Mohd Asri shares: “There was one patient who had two surgeries, which unfortunately, didn’t improve the condition as the tendon had already undergone multiple injections.
“The anatomy was distorted and whatever repair the surgeons tried to do didn’t heal well as the cortisone had left a residual effect on the tendon.
“So, if the doctor offers you a cortisone injection on the first visit, try not to say yes; try to take other routes first.
“More than 95% of the time, conservative treatment will work.”
If the patient listens to the doctor and does physiotherapy, he can easily recover.
“Medically, things are pretty straightforward when you lay everything out on the table.
“But if you start hiding things from us (doctors) and don’t divulge all that we need to know, that complicates matters at the expense of the patient.
“So patients have to be truthful.
“We (orthopaedists) are also guilty of being impatient because we’re always rushing to the operation theatre!” he admits.
“If I see that the patient is having difficulty following my recommendations, then I would refer him to a sports medicine physician for better understanding of the case.
“These physicians sometimes spend more time to talk to the patient because they understand the sportsman’s mentality and why they need to urgently return to sports.”
Surgery is always the last resort.
The worst case scenario is when the patient starts losing strength and range of motion, and it starts to affect other parts of their body like shoulder and wrist.
Dr Mohd Asri says: “Because the elbow is stiff, they have to manoeuvre their hand in a different way to perform the task and this becomes a functional disability.
“We want to rectify this.”
However, he adds that there is no guarantee that the problem won’t recur after conservative treatment.
Preventive measures
To minimise the occurrence of tennis and golfer’s elbow, one has to know how to use one’s equipment properly, whether it is a tennis racquet, golf stick, screwdriver or hammer.
“It may take time to get the feel of using the proper technique, but that’s the only way to prevent injuries.
“Having said that, even well-trained sportsmen can get these conditions because of their mentality.
"They are highly competitive and want to train and train.
“No matter how fit you are, if you overtrain, you can get injuries,” says Dr Mohd Asri.
He notes that there are specific strengthening exercises for the forearm muscles, e.g. wrist flicks using light dumbbells and sideways wrist movements to allow the tendons more mobility to move freely.
“By doing these, when the force strikes the hand during the activity, it will end up in the muscle rather than in the attachment to the bone – that’s the benefit of having strong muscles.
“Some coaches recommend wearing a strap to absorb the impact or pressure whenever there is a hard strike while hitting the ball.
“You can purchase elbow straps from pharmacies... there are many affordable ones in the market where the pressure and tightness can be adjusted.
“Still, it’s best to strengthen the forearm muscles as you don’t want to be dependent on external gadgets,” he says.
