ESPORTS INJURIES: TAKE A GRIP ON GOLFER’S ELBOW

Medial elbow pain is uncommon, with medial epicondylosis reported to have < 1% prevalence, just one-third of the frequency of lateral epicondylosis. While medial epicondylosis is often described in golfers, it is also frequently found among manual laborers, “overhead” athletes, and individuals who require repetitive use of the elbow, forearm, and wrist, especially in tasks involving a combination of pronation of the forearm and wrist flexion.

Relevant Anatomy of the Elbow: The Medial Epicondyle

On the inside of your elbow is a bony bump, known as the medial epicondyle, which serves as the origin of the common flexor tendon comprising of the pronator teres, the palmaris longus, the flexor carpi radialis, and the flexor carpi ulnaris muscles. While these muscles collectively flex your wrist, they also may serve other function:

• Pronator Teres: also forearm pronation (rotating downward)
• Flexor Carpi Radialis: also wrist radial deviation
• Palmaris Longus: when present, also flexes the wrist
• Flexor Carpi Ulnaris: also wrist ulnar deviation
• Flexor Digitorum Superficialis:assist in wrist flexion but also flexion of the four fingers at the metacarpophalangeal and proximal interphalangeal joints

All of these muscles are supplied by the median nerve, the nerve associated with the carpal tunnel syndrome, except for the flexor carpi ulnaris, which is innervated by the ulnar nerve or the nerve primarily affected in cubital tunnel syndrome. The ulnar nerve is of particular importance as this structure passes the medial epicondyle through the cubital tunnel and should be a consideration in the assessment of medial elbow pain.

With medial epicondylosis, the pathology occurs most frequently in the musculotendinous origin of the flexor carpi radialis and pronator teres, but tears can also occur in the palmaris longus, flexor digitorum superficialis, and flexor carpi ulnaris.

The Biomechanics of Medial Epicondylosis

Medial epicondylosis, or the widely known "golfer's elbow," is similar to lateral epicondylosis ("tennis elbow") in such a way that both conditions are caused by overuse and repetitive stress on the associated common tendon origin. In golf, strain from repeated, forceful wrist flexion with twisting in of the forearm towards the body during a golf club swing (from the top of the backswing to just before ball impact) can cause degeneration in the common flexor tendon origin. Although traditionally believed as an inflammatory process, recent studies have shown that both these conditions involve a degenerative state, thus should be appropriately labeled as “epicondylosis” and not “epicondylitis,” which suggests inflammation.

In gaming, players who particularly use a computer mouse place their arms in tensed posture for a prolonged period. Muscles and tendons get damaged due to overstretching and, with repetitive overuse, develop medial elbow pain due to constant pull on the tendon origin. The mechanism of injury is largely eccentric loading or a lengthening contraction of the flexed and pronated forearm, accompanied by valgus stress to the elbow.

How to Know If You Are Experiencing Medial Epicondylosis

Gamers complain of persistent medial-sided elbow pain and tenderness that gets worse with gripping activities. The pain usually points to an area just below the medial epicondyle and may spread down the arm, usually on the inner side of the forearm, the wrist, and occasionally in the fingers. Moving the wrist as well as the fingers while using the console or mouse can trigger the symptoms. Tenderness over the medial epicondyle may also be present but without evidence of swelling or redness, characteristic of an inflammation. Other symptoms are elbow stiffness, hand and wrist weakness, and a numb or tingling feeling in the fingers mostly in the ring and little fingers, although this has to be further examined for associated conditions, such as ulnar neuritis.

• Insidious onset of pain on the inner side of the elbow, sometimes extending along the inner side of the forearm.
• Pain is present when making a fist
• Tenderness 5-10 mm below and front to the medial epicondyle
• Elbow stiffness
• There may be a weakness of the hand and wrist (weak handgrip)
• Pain with resisted forearm pronation and wrist flexion

Medial Epicondylosis Test  (Golfer’s Elbow Test): The patient is seated or standing with his fingers in a fist position. While palpating the medial epicondyle and holding the patient’s wrist with the other hand, the forearm is passively supinated and the elbow and wrist are extended. A positive test would be a complaint of pain or discomfort in the region of the medial epicondyle.

How to Treat a Gamer’s Medial Epicondylosis

While most patients respond to conservative treatment, medial epicondylosis can be disabling and chronic. Medial epicondylosis has a close relationship to cubital tunnel syndrome due to the proximity of the site of pathology so any symptoms related to ulnar neuritis can have a great impact on treatment and prognosis. This has to be differentiated before appropriate treatment can be provided.

ACUTE:  The goal of the treatment of acute medial epicondylosis is to control elbow pain. The rest, ice, compression, and elevation (RICE) protocol remains the first treatment for soft-tissue injuries.

• Withdrawal from a game or activity that triggers the condition.
• Activities that aggravate the condition may be modified by decreasing the amount, frequency, or intensity of activity.
• Totally resting is not advisable. Protective braces and splints are available to control elbow, forearm, and wrist movement.
• Icing is applied through ice massage for 3 to 5 minutes, ice pack for 15 minutes, or ice water bath for 10 to 15 minutes.
• Icing can also be done after completing the exercise, stretching, and strengthening. Care should be taken to avoid over-icing as there is a possibility of ulnar nerve injury.
• Compression using a bandage or a specialized garment that provides both cryotherapy and compression simultaneously can help alleviate swelling and inflammation
• Elevation if there is edema of the wrist or fingers
• Pharmacologic pain reliever

REHABILITATION:  Rehab goals include maintaining or improving the flexibility and strength of the wrist and finger flexors, as well as the related muscles. Also, provide preventive strategies. Rehab goals include maintaining or improving the flexibility and strength of the wrist and finger flexors, as well as the related muscles, and preventing the recurrence or onset of the condition. Frequent stretching along with high repetition, a low resistance exercise program can help with deal with elbow pain from medial epicondylosis.

1. Friction Massage– Friction massage aids in recovery by activating the body’s tissue repair mechanisms. It promotes increased blood flow and soft tissue extensibility. With your thumb, gently apply a back-and-forth stroking over the tendon at the point of greatest tenderness, perpendicular to the tendon fibers (cross-fiber) for 1 to 2 minutes.
2. Stretching Exercise– All patients are instructed to stretch the wrist flexors even with no flexibility deficits. Stretching can provide pain relief by releasing tension on the wrist flexor muscles and improving blood flow to the area.

• Extend your affected arm in front of you with elbow straight, forearm rotated outward (palm facing up), and your shoulders pulled back while allowing your hand to fall back in extension.
• With your free hand, pull the affected hand further into wrist extension.
• Hold for 15-30 seconds and repeat three times.

3. Strengthening Exercise – Attention is given to the eccentric strengthening of the wrist flexors.
   • Rest the affected arm on the table with your forearm turned outward and palm facing up.
   • Hold a weight in your hand and allow your hand to hang off the edge of the table.
   • With your free hand, bend the affected wrist into flexion while lifting the weight.
   • Gradually lower the weight into wrist extension.
   • Repeat 10 to 15 times for three sets.

Soft Tissue Mobilization: Recover like a Pro with  Recovapro

Avoid medial epicondylosis with Recovapro. A variety of soft tissue mobilization techniques can be applied using Percussive Vibration Therapy by Recovapro. Goals include reducing medial elbow pain, promoting faster tissue healing by increasing blood flow, and increasing soft tissue extensibility.

Note:Terms used to describe the techniques are just for reference and comparison to actual manual therapy. The procedures are presented as if a manual massage is applied using the Recovapro massage gun.

• With the round-head attachment, a deep friction techniqueis performed by gliding the Recovapro massage gun in small circular movements across the common wrist flexor tendon at the outside of the elbow. Use light pressure at a lower intensity, preferably 1 or 2, to increase blood flow and desensitize the area for a more thorough workup. Stay for 15 to 20 seconds before proceeding.
• Glide the Recovapro massage gun along the muscle belly of the wrist flexors to promote relaxation and increase tissue extensibility. Apply cross-fiber, longitudinal stripping, and compression broadening using a higher intensity, preferably intensity 3, at moderate pressure.
• Perform active-release technique by moving the forearm into pronation and supination, and the wrist into various positions. Keep the gun over the areas of maximum tenderness with increasing pressure until tension release is felt.
• Finish a session at a maximum of 90 seconds and repeat twice daily.

PRECAUTION: avoid the bony prominence while using the massage gun. This may cause discomfort and may aggravate the condition.