Golfer’s Elbow and Regenerative Modalities
The US Open is being held at Oakmont Country Club outside of Pittsburgh, Pennsylvania this year. This is arguably, the most difficult if not one of the most difficult golf courses in the world. The US Open is always a severe test of golfing skills with fast greens and deep rough. At Oakmont, the rough has grown to be 5 inches deep and the best golfers in the world are having a difficult time advancing their ball from it.
How Golfer’s Elbow Develops on the Course
With a harder swing because of the deep rough, force is transferred to the medial aspect of the elbow, thus the etiology of golfer’s elbow.
Definition and Demographics of Medial Epicondylitis
Golfer’s elbow or medial epicondylitis is a chronic tendinopathy affecting the common flexor tendon at the medial aspect of the elbow. This is a tendinopathic condition involving degeneration of the flexor pronator origin on the medial epicondyle. It develops with repetitive wrist flexion and forearm pronation. This motion is central to the development. Although less common to lateral epicondylitis (tennis elbow), medial epicondylitis can be extremely debilitating. Medial epicondylitis accounts for 10-20% of all epicondylitis cases. The highest prevalence among age groups are ages 45-64 and more common in women than men. In professional athletes, when chronic, can cause a career ending injury that ultimately leads to surgical intervention.
Beyond Golf: Other Causes of Golfer’s Elbow
Medial epicondylitis can result from playing golf but is also found in other sports such as football, racquet sports, archery, bowling, weightlifting, and javelin throwing. Pitchers and overhead throwing athletes often develop the disease because of high energy valgus forces during the late cocking then acceleration phase. In golfers, it is thought to occur from the top of the backswing to ball impact. However, 90% of the cases are not sports related. Labor intensive occupations with forceful, repetitive activities including professions in carpentry, plumbing and construction are also implicated.
Anatomy of the Medial Epicondyle and Flexor-Pronator Group
The median epicondyle of the humerus serves as the origin for the flexor pronator muscle group of the forearm. These muscles include:
- Flexor carpi radialis
- Flexor carpi ulnaris
- Palmaris longus
- Flexor digitorum superficialis
- Pronator teres
The median epicondyle is the common origin of the flexor and pronator muscles of the forearm. The above muscles originate on the median epicondyle and are innervated by the median nerve. The flexor carpi ulnaris also inserts on the median epicondyle and is innervated by the ulnar nerve. Together, these five muscles share the same common origin, forming the conjoined tendon of the median epicondyle of the humerus. This tendon is approximately three centimeters long, crosses the medial ulnohumeral joint and runs parallel to the ulnar collateral ligament where it also serves as a secondary stabilizer of the elbow.
The ulnar nerve runs in close proximity and can be involved with ulnar nerve neuritis in chronic cases causing numbness in part of the hand and fingers.
The tendon complex is relatively avascular contributing to the difficulty in healing once injured.
Types of Golfer’s Elbow
Type 1 golfers elbow involves pain at the joint and pain with flexion of the wrist and pronation.
Type 2 golfers elbow involves pain at the joint and pain with wrist flexion and forearm pronation but also numbness in the ulnar nerve distribution. This occurs in 20% of cases. This is much more serious and often leads to surgical intervention.
Causes and Pathophysiology
Golfer’s elbow or medial epicondylitis is not an inflammatory condition but rather a tendinosis which is characterized by collagen disorganization, fibroblast proliferation and neovascularization. The healing cascade is chaotic causing chronicity of this condition.
Major causes of medial epicondylitis are:
- Repetitive stress from wrists flexion and forearm pronation (eg. Golf, baseball, carpentry)
- Poor biomechanics and improper technique
- Age related degeneration of the tendon
- Overuse injury in occupational settings and athletic events such as trying to hit a golf ball out of deep rough.
Medial epicondylitis is an overuse tendinopathy due to chronic repetitive concentric or eccentric loading of the wrist flexors and pronator teres, resulting in angio- fibroblastic changes. Repetitive activity leads to recurrent microtears within the tendon and subsequent tendinosis. There is no bony inflammation. As the tendon undergoes repetitive microtears, there is remodeling of the collagen fibers and increased mucoid ground substance. Focal necrosis or calcifications can occur. Collagen strength decreases leading to increased fragility, scar tissue formation, and tendon thickening.
In severe long-standing cases, the ulnar nerve can be impinged or trapped.
Clinical Presentation
- Medial elbow pain made worse by wrist flexion or gripping.
- Tenderness to palpation at the medial elbow area.
- Severe pain easily reproduced on resisted wrist flexion and pronation.
Diagnosis is usually clinical but if severe ulnar nerve neuritis present, ultrasound or MRI is appropriate to rule out other pathologies.
Conservative and Regenerative Treatment Options
Conservative management includes:
- Rest
- Activity modification
- Physical Therapy
- Bracing or orthosis
- Non-Steroidal Anti-Inflammatory Agents
- Corticosteroid injections may relieve pain initially but may impair long term healing and weaken or degrade tissues.
- Surgery is reserved for severe chronic cases especially with ulnar nerve involvement.
- Platelet Rich Plasma
- Shockwave Therapy
Platelet Rich Plasma (PRP) for Golfer’s Elbow
Platelet rich Plasma is an autologous blood derived concentrate, rich in growth factors, cytokines and bioactive proteins. Platelet Rich Plasma has been proven to regenerate and repair damaged tissues.
Mechanism of action
- Stimulates tenocyte proliferation.
- Promotes neovascularization.
- Enhances and promotes collagen synthesis.
- Reduces pro-inflammatory cytokines.
Extracorporeal Shockwave Therapy (ESWT)
Extracorporeal shockwave therapy delivers acoustic pressure waves that stimulate biological repair responses.
Mechanism of action
- Promotes neovascularization.
- Stimulates tenocyte activity and collagen synthesis.
- Disrupts pain receptor nerve endings immediately modulating pain.
- Facilitates phagocytosis and removal of dead or damaged tissues.
Combining PRP and Shockwave for Enhanced Recovery
Combining platelet rich plasma with extracorporeal shockwave therapy provides synergistic effects. PRP would provide the biologic stimuli needed for repair while ESWT would enhance local vascular profusion and cellular recruitment. This combined approach aligns with modern regenerative principals.
Studies Supporting PRP and Shockwave Therapy
Golfers Elbow
StatPearls 2025 Jan PMID 30085542
Platelet Rich Plasma Injections as an Alternative to Surgery in Treating Patients with Medial Epicondylitis: A Systematic Review
Cureus 2022 Aug 25;14(8):e28378 PMID 36171858
Objective: To synthesize the available information on the effectiveness of platelet rich plasma injections against surgery as therapy strategies for medial epicondylitis.
Conclusion: Evidence from the reviewed studies shows that platelet rich plasma injections are just as effective as medial epicondylitis surgery in relieving pain and restoring function for those with ME, especially in the short and midterm. Success rate, pain free status, quality of life was comparable in both surgery and PRP groups.
Platelet Rich Plasma is an Equal Alternative to Surgery in the Treatment of Type 1 Medial Epicondylitis
Orthop J Sports Med 2020 Mar 25;8(3):2325967120908952 PMID 32232070
Background: Medial epicondylitis is characterized as an overuse injury resulting in pathological alterations of the common flexor tendon at the elbow. Platelet Rich Plasma has recently become of interest in the treatment of musculoskeletal conditions as an alternative to operative management.
Purpose: To compare the outcomes of recalcitrant type 1ME after treatment with either PRP or surgery.
Conclusion: The mean follow up was 3.9 years. The use of PRP showed clinically similar outcomes to those of surgery in recalcitrant type 1ME. PRP can be considered as an alternative to surgery in the treatment of recurrent ME, with an earlier time to full range of motion and time to pain free status compared with surgery.
Medial Elbow Pain Syndrome: Current Treatment Strategies
Orthopedics 2023 Mar-Apr;46(2): e81-e88 PMID 35876779
Abstract: Median elbow pain is a common presentation that can be a challenge to appropriately treat for the orthopedic surgeon. A good outcome is typically achieved with adequate treatment of tendon degeneration at the common flexor tendon origin. Mainstay treatment is nonoperative modalities such as stretching, rest, activity modification, therapy and injections. If nonoperative management fails, intermediate interventions such as extracorporeal shockwave therapy, platelet rich plasma, prolotherapy and ultrasound guided percutaneous tenotomy can be attempted. Surgical treatments are dictated based on the severity of the pathology.
Juventix Regenerative Medical: Innovators in PRP and Shockwave Therapy
Juventix Regenerative Medical is an industry leader in the regenerative medical field. Our Platelet Rich Plasma Kits are designed for safety, sterility and effectiveness. Our kits are FDA cleared and scientifically manufactured to provide a platelet concentrate, devoid of red blood cells with a minimum number of leukocytes that are critical for the regenerative process.
LED Platelet Activation Technology
Juventix Regenerative Medical offers a patented LED Activator to activate the platelets and begin the regenerative process. The activation is a critical step in the release of growth factors, cytokines and bioactive proteins from the granules that are contained on the platelets and is accomplished by LED light. This negates the use of chemical additives such as Calcium Chloride, Thrombin or Collagen. This mode of activation by LED light provides sustained growth factor release versus older methods of activation while adhering to the minimal manipulation standards of the FDA.
PhysioPRO Shockwave System: Advanced Healing Technology
Juventix Regenerative Medical is proud to be a distributor of the PhysioPRO Shock Wave System. This clinical grade radial shock wave device induces intracellular and extracellular reactions to assist in the repair and regeneration of tissues. The wave activates cellular pathways that drive the healing process. Shock wave treatment stimulates angiogenesis and neogenesis. These metabolic processes form new blood vessels to better oxygenate damaged tissues and mediates repair. The shock wave also modulates and overloads pain receptors to decrease pain. Treatments with the PhysioPRO can attract mesenchymal stem cells to migrate to the damaged area for enhanced cellular regeneration. The PhysioPRO complements Platelet Rich Plasma and they both work synergistically in repair and regeneration. This dual approach would be advantageous in the treatment of medial epicondylitis.
Support and Solutions for the Regenerative Professional
Juventix Regenerative Medical has a vast array of products, devices and services tailored for the medical and regenerative professional. Platelet Rich Plasma Kits and the PhysioPRO are two of the many devices that offer the latest in the treatment of soft tissue, ligamentous and tendon injuries.
With our premier line of products and support from our experiences staff, Juventix Regenerative Medical is poised to aid any professional in enhancing clinical outcomes while increasing patient satisfaction.
RESTORE, REVIVE, REGENERATE – JUVENTIX REGENERATIVE MEDICAL
Regenerative Regards,
Dr. Robert McGrath
