Golfer’s elbow, which is also known as medial epicondylitis, is a painful condition of the upper extremity that is caused by repetitive overuse or misuse of the flexor tendons of the forearm. Over time, microscopic tears begin to occur at the origin of the musculotendinous units of the pronator teres, flexor carpi radialis and flexor carpi ulnaris, and palmaris muscles (Fig. 57.1). The repetitive process of tearing and healing of the musculotendinous units of the flexor tendons sets up an inflammatory process that ultimately results in pain and functional disability. If not properly treated, complete rupture of the tendinous insertion of these flexor muscles can occur (Fig. 57.2). It has been postulated that a combination of the poor blood supply of the flexor tendons combined with the significant concentric and eccentric stresses placed on these tendons may be responsible for the evolution of this common pain syndrome.

Activities that require increased grip pressure and high torque twisting of the wrist have been implicated in the evolution of golfer’s elbow. The biomechanics responsible for the development of golfer’s elbow include activities that have in common repetitive flexion and sudden arrested motion, for example, driving golf balls with too heavy of a golf club and overhead throwing. Carrying heavy suitcases, computer bags, and brief cases have also been implicated.

The signs and symptoms frequently observed in patients suffering from golfer’s elbow include pain that is localized to the medial epicondyle with maximal point tenderness at the site of the insertion of the musculotendinous units of the pronator teres, flexor carpi radialis and flexor carpi ulnaris, and palmaris muscles. The pain is constant in nature with the patient experiencing an acute exacerbation of pain with any activity that requires gripping with the hand, extending the wrist, or pronating the forearm. The patient suffering from golfer’s elbow may complain of significant sleep disturbance with awakening when the patient rolls over onto the affected elbow. On physical examination, there is exquisite point tenderness to palpation at or just below the medial epicondyle. Careful palpation of the area may reveal a band-like thickening of the flexor tendons, and color may be noted. Grip strength is often diminished and patients will exhibit a positive golfer’s elbow test. The golfer’s elbow test is performed by stabilizing the patient’s forearm and then having the patient clench his or her fist and actively flex the wrist (Fig. 57.3). The examiner then attempts to force the wrist into extension. Sudden, severe pain is highly suggestive of golfer’s elbow.

Golfer’s elbow can be confused with a C6 to C7 radiculopathy although patients suffering from cervical radiculopathy will usually have coexistent neck symptomatology and more proximal upper extremity pain. Electromyography and nerve conduction velocity testing are useful in helping in the differentiation of golfer’s elbow from cervical radiculopathy and other nerve entrapment syndromes. Plain radiographs, ultrasound imaging, and magnetic resonance imaging are indicated in all patients who are thought to be suffering from golfer’s elbow in order to confirm the diagnosis as well as to rule out occult bony pathology involving the medial epicondyle and elbow joint and to identify occult fractures, masses, or tumors that may be responsible for the patient’s symptomatology (Figs. 57.4 and 57.5). Based on the patient’s clinical presentation, additional testing may be indicated, including complete blood count, uric acid, sedimentation rate, and antinuclear antibody testing. The ultrasound-guided injection technique described below serves as both a diagnostic and therapeutic maneuver as ultrasound imaging can clearly delineate pathology of the flexor musculotendinous units at their insertion on the medial epicondyle.

The key landmarks when performing ultrasound-guided golfer’s elbow are the flexor tendons of the pronator teres, flexor carpi radialis and flexor carpi ulnaris, and palmaris muscles and their point of origin on anterior facet of the medial epicondyle of the elbow (see Fig. 57.1). Cubital and olecranon bursitis may coexist with golfer’s elbow, further confusing the clinical presentations. The ulnar nerve is in proximity to the medial epicondyle and subject to needle-induced trauma during this injection technique. The nerve exits the axilla, and it passes inferiorly adjacent to the brachial artery. At the middle of the upper arm, the ulnar nerve turns medially to pass between the olecranon process and medial epicondyle of the humerus. Continuing its downward path, the ulnar nerve passes between the heads of the flexor carpi ulnaris moving radially along with the ulnar artery.