TABLE OF CONTENTS

Page. No
CERTIFICATE (Guide )

ii

CERTIFICATE (External examiner)

iii

CERTIFICATE ( HOD)

iv

CERTIFICATE (Student)

ACKNOWLEDGEMENT

vi

DEDICATION

vii

TABLE OF CONTENTS
LIST OF FIGURES
1 . INTRODUCTION

11-13

2. REVIEW OF LITRATURE

14

Anatomy

15-23

Biomechanics

23-24

Epidimiology&Etiology

24

Risk Factors

24-26

Pathophysiology

26

Symptom

27

Diagnosis

27-28

Investigation

29-30

Prevention

30-31

Management

31-49

3 . CASE STUDY

50-58

4 . CONCLUSION

59-60

5 . REFERENCES

61-67

6 . APPENDICES

68

APPENDIX -A

VAS SCALE

69-70

APPENDIX B

CONSENT FORM

71-72

LIST 0F FIGURES
Figure 2.1: Left elbow-joint

page no-16

Figure.2.2: Capsule of elbow-joint

page no-18

Figure.2.3: Muscle of forearm

page no-21

Figure.2.4: painfull area of golfers elbow

page no-27

Figure.2.5: Reverse cozen test

page no-29

Figure.2.6: MRI showing medial epicondylitis

page no- 29

Figure.2.8: Strengthening eccentric exercises

page no-40

A: starting position
Figure.2.9: Strengthening eccentric exercises

page no-41

B: End position
Figure.2.10: Stretching Exercise

page no-46

Figure.2.11: Ultrasound therapy

page no-37

Figure.2.12: Application of TENS electrode

page no-38

10

CHAPTER-1
INTRODUCTION

11

Golfer's elbow, or medial epicondylitis, is tendinosis of the medial epicondyle of

the elbow. It is in some ways similar to tennis elbow. The anterior forearm contains several
muscles that are involved with flexing the digits of the hand, and flexing and pronating the wrist.
The tendons of these muscle come together in a common tendinous sheath, which originates
from the medial epicondyle of the humerus at the elbow joint. In response to minor injury, or
sometimes for no obvious reason at all, this point of insertion becomes inflamed.
The condition is called Golfer's Elbow because in making a golf swing this tendon is
stressed, especially if a non-overlapping (baseball style) grip is used; many people, however,
who develop the condition have never handled a golf club. It is also sometimes called Pitcher's
Elbow due to the same tendon being stressed by the throwing of objects such as a baseball, but
this usage is much less frequent. Other names are Climber's Elbow and Little League Elbow: All
of the flexors of the fingers and the pronators of the forearm insert at the medial epicondyle of
the humerus to include: pronator teres, flexor carpi radialis, flexor carpi ulnaris, flexor digitorum
superficialis, and palmaris longus; making this the most common elbow injury for rock climbers,
whose sport is very grip intensive. The pain is normally caused due to stress on the tendon as a
result of the large amount of grip exerted by the digits and torsion of the wrist which caused by
the use and action of the cluster of muscles on the condyle of the ulna.[1]

12

Epicondylitis is much more common on the lateral side of the elbow (tennis elbow), rather than
the medial side. In most cases, its onset is gradual and symptoms often persist for weeks before
patients seek care. In golfer's elbow, pain at the medial epicondyle is aggravated by resisted wrist
flexion and pronation, which is used to aid diagnosis. On the other hand, tennis elbow is
indicated by the presence of lateral epicondylar pain precipitated by resisted wrist
extension. Although the condition is poorly understood at a cellular and molecular level, there
are hypotheses that point to apoptosis and autophagic cell death as causes of chronic lateral
epicondylitis. So athletes, like pitchers, must work on preventing this cell death via flexibility
training and other preventative measures.[2]
. Although termed golfers elbow, medial epicondylitis occurs often in baseball pitchers
and in those who participate in a variety of other sports and occupational activities that create
valgus force at the elbow.
The rehabilitation program begins with wrist flexor and forearm pronator stretching and
progressive isometric exercises. As flexibility, strength, and endurance improve eccentric and
concentric resistive exercises are included. [3]
Patients with this condition will usually benefit from following the R.I.C.E. Regime. The
R.I.C.E regime is beneficial in the initial phase of the injury (first 72 hours) or when
inflammatory signs are present (i.e. morning pain or pain with rest). Anti-inflammatory
medication may also significantly hasten the healing process by reducing the pain and swelling
associated with inflammation.
Therapy will include a variety of exercises for muscle/tendon reconditioning, starting with
stretching and gradual strengthening of the flexor-pronator muscles. Strengthening will slowly

13

begin with isometrics and progresses to eccentric exercises helping to extend the range of motion
back to where it once was. After the strengthening exercises, it is common for the patient to ice
the area.[3,4]

CHAPTER-2
REVIEW OF LITERATRE

14

ANATOMY
Joints
The three joints are the humeroulnar, the humeroradial and upper radioulnar joint . Their
two functions are flexion/extension, which is performed at the humeroulnar and humeroradial
joints, and pronation/supination, which takes place at the upper radioulnar joint in close
association with the lower radioulnar joint..(5,6)
The three joints work closely together and make pronation and supination movements
possible whatever the extent of flexion or extension of the elbow:
The humeroulnar joint acts as a hinge. The articular surfaces on the humerus are the spoolshaped trochlea with, proximal to it, the coronoid fossa and the olecranon fossa (dorsal aspect)
The other part of the joint is formed by the olecranon, with its trochlear notch and its
olecranon(proximal) and coronoid (distal) processes.(5,6

15

Figure 2.1: Left elbow-joint

The humeroradial joint a ball-and-socket joint consists of (a) the spheroidal capitulum of the
humerus and (b) the proximal surface of the head of the radius. Proximal to the capitulum lies the
radial fossa and beside it a capitulotrochlear sulcus (between capitulum and trochlea). The
articular facet of the radius, with which the proximal part of the humeroradial joint articulates, is
at the top of the head of the radius. This facet exactly follows the shape of the humeral
capitulum. Because it articulates with the capitulotrochlear sulcus at the ulnar side, it allows
pronationsupination movements as well.[5,6,7)]

16

The upper radioulnar joint is a trochoid (cone-shaped) joint. The circumference of the head of
the radius articulates with the radial notch of the ulna.
The three joints lie within the same lax joint capsule, which is spanned by muscular fibres of the
brachialis, triceps and anconeus muscles.
At the distal end of the humerus lie the two epicondyles, of which the medial one is more
developed than the other. They are both extracapsular.[5,6,7]
Ligaments
The capsule is reinforced by strong lateral ligaments. The medial collateral ligament has
an anterior part, which runs from the medial epicondyle of the humerus towards the annular
ligament, a middle part towards the coronoid process, and a posterior part, directed towards the
olecranon. All three parts are reinforced by an oblique band (ligament of Cooper) distally on the
ulna.The lateral collateral ligament connects the lateral epicondyle to the radial annular ligament
(anteriorly via the radial collateral ligament and posteriorly via the lateral ulnar collateral
ligament which inserts at the supinator crest of the ulna) and is interwoven with the superficial
extensor muscles. These ligaments help to maintain the articular surfaces in contact with each
other. They also limit lateral movements. Other ligamentous structures are: [5,6,7]

17

Figure 2.2: Capsule of elbow-joint

The radial annular ligament, a U-shaped fibrous collar, covered with cartilage at its inner aspect,
joins the radial head to the proximal ulnar extremity so that they can articulate. It plays an
important role in pronation supination
The quadrate ligament attaches the radial neck to the distal aspect of the radial notch of the ulna.
The oblique cord extends inferolaterally from the lateral border of the tuberosity of the ulna to
the radius, just below its tuberosity . It prevents downwards movement of the radius.
The interosseous membrane and the oblique cord join the two bones of the forearm to prevent
any longitudinal movement and assist as a fulcrum in pronationsupination (i.e. diagonal
rotation). They are both syndesmosis connections. [5,6,7)]

18

Muscles and Tendons

Flexor muscles:
The flexor muscles are the brachialis, the brachioradialis and the brachial biceps.Their
action is maximal when the elbow is flexed at 90 [5,6,7].
Brachialis:
This runs from the anterior and distal aspect of the humerus towards the ulnar tuberosity
and the joint capsule.It is a monoarticular muscle. Its only function is to bend the elbow,
irrespective of the degree of pronationsupination of the forearm. [5,6,7]
Brachioradialis:
This muscle has its origin at the lateral supracondylar ridge of the humerus and inserts at
the radial aspect of the styloid process of the radius. It brings the pronated or supinated forearm
back in the neutral position between pronation and supination. In this position it acts as a flexor
of the elbow, an action which diminishes when the forearm is held in supination. [5,6,7]
Biceps:
This is the dominant flexor of the elbow. It originates from the scapula, where it has two
heads, the long head from the supraglenoid tubercle, the short head from the coracoid process,
and it inserts with a strong thick tendon at the radial tuberosity. Part of the tendon blends into the
aponeurosis of the forearm at the ulnar side Because the biceps is a biarticular muscle, it also acts
on the shoulder. Its essential function is elbow flexion but its secondary function is supination of
the forearm. Such supination action of the biceps increases the more the elbow is flexed and is
maximal at 90. it diminishes again when the elbow is fully flexed. [6,7]

19

Extensor muscles:
Extension of the elbow is performed by two muscles: the triceps and the anconeus. [6,7]
The triceps:
The triceps originates from three heads as its name implies: the long head from the
infraglenoid tubercle of the scapula, the medial head from the dorsal aspect of the humerus,
distally to the sulcus for the radial nerve, and the lateral head also from the dorsal aspect of the
humerus, proximally to that sulcus. The three muscular bodies join in one tendon that inserts at
the olecranon and at the posterior aspect of the joint capsule . [6,7]
Because the triceps is partly biarticular, its extension action to the elbow joint depends
not only on the position of the elbow but also on the position of the shoulder. The triceps has its
maximal force in a movement which combines the two: elbow extension and shoulder extension.
[6,7]

Anconeus:
Originating at the dorsal aspect of the lateral epicondyle of the humerus and at the lateral
collateral ligament, this muscle runs towards the posterior and proximal aspect of the ulna and
the joint capsule. It may be considered as a continuation of the lateral head of the triceps. It thus
helps the triceps in its extensor function and also spans the joint capsule. From the clinical point
of view this muscle may be ignored. [6,7]

20

Figure 2.3: Muscle of forearm

Supinator muscles:
Supination movement is the result of the action of two muscles: the supinator brevis and
brachial biceps [7]
Supinator brevis:
This takes origin at the supinator crest of the ulna, the lateral epicondyle, the radial
collateralligament and the annular ligament. The muscular fibres encircle the radius and insert
via a short tendon at the radius between the radial tuberosity and the insertion of the pronator
teres muscle. The muscle supinates the forearm in whatever position there is between flexion and
extension of the elbow.[7]

21

Pronator muscles:
Pronation is performed by two muscles: the pronator quadratus and the pronator teres [7]
Pronator quadrates:
This is at the distal aspect of the forearm. It runs from the distal and anterior part of the
ulna to the distal and anterior part of the radius, so encircling the ulna. [7]
Pronator teres:
The pronator teres has a multiple origin: the humeral head from the medial epicondyle of
the humerus (partly from the common flexor tendon) and the ulnar head from the coronoid
process of the ulna. Its insertion lies halfway down the radius at the lateral aspect. Because the
pronator teres is a biarticular muscle, theoretically it also assists in the flexion of the elbow but
this action is of course very secondary. The pronator muscles are not as strong as the supinator
muscles. [7]
Flexors of wrist and fingers:
The flexors of the wrist and fingers take their origin at the medial epicondyle of the
humerus, mainly in a common flexor tendon which has a superficial and a deep layer. The
superficial layer consists of the humeral head of the pronator teres muscle, the flexor carpi
radialis, the palmaris longus, the humero-ulnar head of the superficial flexor digitorum and the
humeral head of the flexor carpi ulnaris. [7]
Flexor carpi radialis:
Starting at the anterior aspect of the medial epicondyle, this muscle runs towards the
wrist. Its main function is flexion of the wrist; its radial deviation function is secondary. [7,8]

22

Flexor carpi ulnaris:

Starting with a humeral head at the medial epicondyle, this also has an ulnar head at the
olecranon and the upper part of the posterior margin of the ulna. It flexes the wrist and assists the
extensor carpi ulnaris in performing ulnar deviation of the wrist. [7,8]
Palmaris longus:
This is not always present. When it is, it runs towards the hand into the palmar
aponeurosis, of which it is a tensor. It also helps in flexion of the wrist. [7,8]
Superficial flexor digitorum:
The origin is threefold: a humeral head originating from the common flexor tendon at the
medial epicondyle of the humerus, an ulnar head from the coronoid process and a radial head
from the anterior aspect of the radius. Apart from flexion of the fingers, it also assists in ulnar
deviation of the wrist. [7,8]
Flexor pollicis longus:
This lies in the deeper layer. It has a humeral head, originating from the medial
epicondyle and, more important, a radial head originating from the anterior aspect of the radius,
just distal to the supinator muscle and the interosseous membrane. It flexes the thumb and assists
in flexion of the wrist. (7,8)

BIOMECHANICS
The biomechanics of the medial elbow have been most thoroughly defined by the
pitching mechanism. Peak angular velocity and valgus forces exceeding the tensile strength of
the medial musculotendinous and ligamentous structures may be produced primarily during the
acceleration phase, which extends from the point at which forward velocity of the ball is

23

essentially zero to ball release. These forces are transmitted initially to the flexor pronator
musculature at the medial epicondyle and subsequently to the deeper medial collateral ligament.
In an EMG evaluation of the tennis serve, Morris and associates1 corroborated the
biomechanical theories of the baseball pitch. They noted that the highest muscle activity
occurred during the acceleration phase and was seen in the pronator teres of the flexor pronator
mass. They suggested that during this phase the pronator is providing optimal forearm
positioning while transferring momentum and power to the ball. (8)

EPIDEMIOLOGY AND ETIOLOGY

Medial epicondylitis is much rarer than its lateral counterpart, the latter occurring from 7
to 20 times more frequently. It also occurs within the fourth and fifth decades, with apparently
equal male and female prevalence rates. Although termed golfers elbow, medial epicondylitis
occurs often in baseball pitchers and in those who participate in a variety of other sports and
occupational activities that create valgus force at the elbow. (8,9)

RISK FACTORS
Contrary to what the name suggests, you do not have to play golf to develop this
condition. In fact, golfers elbow is more commonly seen in non-golf players than in golf players.
Patients typically develop this condition due to activities involving repetitive wrist flexion
against resistance or forceful or repetitive gripping of the hand. These activities may include
sports or manual work such as: (10,11,12)
Golf (especially those who continually take divots out of the ground)
Tennis (especially those players who put a lot of top spin on the ball)

24

Squash
Badminton
Water skiing
Gymnastics
Body building or weight lifting
Carpentry
Hammering
Painting
Chopping wood
Bricklaying
Repetitive use of a screwdriver
Sewing
Knitting
Working at a computer
It is also common for patients to develop this condition following a sudden increase in
activities that place stress on the forearm flexors (such as involvement in a golf tournament over

25

consecutive days) or due to a change in these activities (such as using a new technique or clubs,
or hitting the ball too hard). In golf players, golfers elbow is often associated with poor swing
technique.
Occasionally, this condition may develop suddenly. This is usually due to a forceful
movement involving a heavy lifting or gripping force through the arm. In golf, this may occur
when mis-timing a shot and taking a divot out of hard ground.
A history of wrist, elbow, shoulder or neck injury may increase the likelihood of a patient
developing this condition. (11,12)

PATHOPHYSIOLOGY
Valgus forces at the elbow create stress in the flexor pronator origin as well as the medial
collateral ligament. Improper technique, poor conditioning, inadequate warm-up, and fatigue can
all lead to inflammation of the flexor pronator mass. The pronator teres and flexor carpi radialis
have been identified as the most common sites of pathologic change. Vangsness and Jobe noted
macroscopic tearing of the flexor pronator origin in 100% of their patients who underwent
surgical treatment for recalcitrant medial epicondylitis.(13)
In 1992 Glousman and associates used cinematography and indwelling electromyography to
examine elbow muscle activity in pitchers with normal elbows and pitchers with medial
collateral ligament injuries. They noted less pronator teres and flexor carpi radialis activity
during the late cocking and acceleration phases in the subjects with collateral ligament injuries.
The authors proposed that flexor pronator overuse subsequently led to progressive medial
ligamentous injury in these subjects.(13)

26

SYMPTOMS
The main symptom of golfer's elbow is tenderness and pain at the medial epicondyle of
the elbow. Pain usually starts at the medial epicondyle and may spread down the forearm.
Bending your wrist, twisting your forearm down, or grasping objects can make the pain worse.
You may feel less strength when grasping items or squeezing your hand into a fist

Figure 2.4: painfull area of golfers elbow

DIAGNOSIS
Medial epicondylitis is characterized by pain along the medial elbow that is worsened by
resisted forearm pronation or wrist flexion. This medial pain is often insidious in onset.
Tenderness is usually distal and lateral to the medial epicondyle, most often over the pronator
teres and flexor carpi radialis. Resisted wrist flexion and forearm pronation exacerbate the pain.

27

The range of motion of the elbow and that of the wrist are usually complete. Normal strength and
sensation are typically noted in the extremity. If, however, concomitant ulnar neuropathy exists,
varying degrees of diminished sensibility in the ring and little fingers, as well as a Tinels sign at
the elbow, may be present. Plain radiographs of the elbow are most often normal. Throwing
athletes however, may have medial ulnar traction spurs and medial collateral ligament
calcification. When evaluating the patient with suspected medial epicondylitis, it is essential to
consider primary ligamentous instability or primary ulnar neuropathy in the differential
diagnosis. Valgus stress testing with the wrist flexed and the forearm pronated will produce pain
and laxity if collateral instability is resent. Maximum elbow flexion and wrist extension for 3
minutes (elbow flexion test) will produce pain and numbness if ulnar neuropathy is present. (14,15)

INVESTIGATION
These are usually not required but may be indicated if the diagnosis is uncertain, eg CRP,
elbow X-ray, MRI. Nerve conduction study and electromyography may be indicated if ulnar
nerve involvement is suspected in patients with golfer's elbow. Reverse cozen test is specially
used to diagnose golfers elbow in clinical setting.
The patient should be seated or standing and should have his/her fingers flexed in a fist
position. The examiner palpates the medial epicondyle with one hand and grasps the patients
wrist with his/her other hand. The examiner then passively supinates the forearm and extends the
elbow and wrist. A positive test would be a complaint of pain or discomfort along the medial
aspect of the elbow in the region of the medial epicondyle. (16,17)

28

Figure 2.5: Reverse cozen test

MRI-:

Figure 2.6: MRI showing medial epicondylitis

29

PREVENTION
Warming up before golfing has been shown to decrease the incidence of golf injuries.
One survey showed that over 80 percent of golfers spent less than 10 minutes warming up before
around. Those who did warm up had less than half the incidence of injuries of those who did not
warm up before playing. Lower handicap and professional golfers were more than twice as likely
to warm up for more than 10 minutes as compared to other golfers. Many of these problems can
be improved by using good swing mechanics. Instruction by a golf pro to improve technique is
one of the best ways to decrease your chances of being injured. A regular exercise program that
includes core strengthening, stretching and strengthening all the major muscle groups can also
help decrease your injury rate and increase your playing time. (18)
A healthy elbow requires a healthy shoulder and wrist joint and strong muscles around the
scapula (shoulder blades) and arms to decrease the load on the smaller forearm muscles.
To prevent overuse and strain in the elbow and forearm:
1.

Take frequent breaks from activities that require extensive hand/wrist motions.

2.

Reduce or avoid lifting objects with the arm extended.

3.

Reduce repetitive gripping and grasping with the hand and wrist. Decrease the overall
tension of gripping.

4.

Avoid the extremes of bending and full extension.

5.

Work or weight-train with the elbow in a partially bent position. Use wrist supports when
weight-training.

30

6.

When using tools, increase the gripping surface by wearing gloves or adding padding.
Use a hammer with extra padding to reduce tension and impact. Hold heavy tools with two
hands.

7.

Use a two-handed backhand in tennis. When hitting a tennis stroke, use your entire lower
body, hip, pelvis, and back, and use less of your elbow. Using the proper technique in tennis can
help reduce symptoms. Re-evaluate the size of your grip, string tension, type of string, new
strokes, and new grips for new strokes, which can all contribute to problems. Some suggest
lowering string tension, finding the heaviest racket that does not affect your swing speed, finding
the largest grip that is comfortable, and using softer strings.

8.

Apply grip tape or an oversized grip on golf clubs. [19]

9.

Patients often have to modify their activities or the particular techniques that lead them to
develop this overuse injury.

10.

This may need to include the help of a coach for sporting activities.

MANAGEMENT
Golfers elbow may be treated by the drug treatment, surgical release and physiotherapy.
Medical Management
Nonsteroidal anti-inflammatory drugs:
NSAIDs have analgesic, anti-inflammatory, and antipyretic activities. Their mechanism
of action is not known, but they may inhibit cyclo-oxygenase activity and prostaglandin
synthesis. Other mechanisms may exist as well, such as inhibition of leukotriene synthesis,

31

lysosomal enzyme release, lipoxygenase activity, neutrophil aggregation, and various cellmembrane functions.(19,20)
Ibuprofen (Motrin, Advil, Nuprin):
DOC for mild to moderate pain. Inhibits inflammatory reactions and pain by decreasing
prostaglandin synthesis.
Naproxen (Naprosyn, Aleve, Naprelan, Anaprox):
For the relief of mild to moderate pain; naproxen inhibits inflammatory reactions and
pain by decreasing the activity of cyclo-oxygenase, which is responsible for prostaglandin
synthesis
Etodolac (Lodine, Lodine XL):
For relief of mild to moderate pain; etodolac inhibits inflammatory reactions and pain by
decreasing the activity of cyclo-oxygenase, which is responsible for prostaglandin synthesis.(20)
Corticosteroid injection
1. Local steroid injection:
Steroids can be injected into the point of maximum tenderness. Extra care is required
with injecting golfer's elbow, to ensure avoiding the ulnar nerve. Superficial injections should be
avoided, as they are ineffective and may cause skin atrophy. Steroid injections can be repeated
after six weeks to two months.
In most situations, steroid injections should not be used as, although they lead to very
good results in the short term (six weeks), they are harmful in the longer term (more than three

32

months). In one study, short-term success rates were greater than for physiotherapy or a waitand-see policy, but in the long term (one year), success rates were greater for both
physiotherapy ;and a wait-and-see policy than for injections. [21] The short-term benefit may be
sufficient to warrant an injection, e.g. for a student about to sit important examinations.[21]

Complications of steroid injections include pain after the injection, and fat atrophy and
depigmentation of skin over the site of injection of strong steroids. If an injection is made into
the tendon, this can be weaken the tendon and risk tendon rupture. Steroid injections should
therefore be given with great care.[22]
Glyceryl trinitrate patches applied over the painful area improve outcomes in the first six
months. Longer-term results have not shown benefit but also no long-term harm.[22]
Acupuncture: this may be effective in the reduction of pain and improvement in the
functioning of the arm.[22] However, the evidence is limited and a Cochrane review was unable to
form a firm conclusion.[22][23]
Autologous blood products, eg platelet-rich plasma (PRP): involves centrifuging a
sample of the patient's blood and then injecting the heaviest layer of plasma (with a higher
concentration of platelets) back into the patient. A recent study found superior cure rates and pain
scores for PRP injections than for steroid injections up to two years after treatment. However,
these procedures are expensive and there is no consensus whether PRP significantly improves
good management.[23] The National Institute for Health and Clinical Excellence (NICE) does not
currently recommend autologous blood injection for tendinopathy.[24]

33

Extracorporeal shock wave therapy has not been shown to be effective for treating tennis
elbow.[24]
Surgery: release of the extensor/flexor origin is occasionally indicated for patients that do
not respond to a sustained period of conservative treatment.[25] There is a marked shortage of
evidence for the effectiveness of surgery.[26,27]
Surgical Management
Epicondylar debridement is rarely indicated but has proven to be effective in cases in
which conservative treatment has failed. In addition, the ulnar nerve may be decompressed
surgically.[28]
A study by Shahid et al of 15 patients (17 elbows) indicated that open surgery can improve elbow
function and strength in cases of recalcitrant ME. After a mean follow-up period of 66 months,
patients showed an improved score (mean decrease of 25.7) on the Disabilities of the Arm,
Shoulder and Hand (DASH) questionnaire, as well as a 10-kg mean increase in grip strength.[29]
Kwon et al found the surgical technique known as fascial elevation and tendon origin
resection (FETOR) to be a safe and effective treatment for chronic recalcitrant ME. The surgery
was performed on 20 adult patients (22 elbows), with pain levels and arm function assessed after
a mean follow-up period of 35.6 months. According to results from the visual analogue scale,
average pain was reduced by 93%, while the DASH questionnaire indicated that, based on
patient perception, arm function equal to that of the healthy population was attained.[30]
The indications for surgical treatment of medial epicondylities include persistent pain at the
medial elbow unresponsive to a well-managed non operative program for a minimum of 6 to 12

34

months, after exclusion of any other pathologic causes for the pain. Historically, there is a dearth
of information regarding the surgical treatment of medial epicondylitis. The various techniques
that have been described range from percutaneous release of epicondylar muscles to open
epicondylectomy. These techniques, however, result I significant flexor-pronator strength deficits
that are particularly debilitating for the athlete or laborer. Vangsness and Jobe15 described the
following technique of reactive-tissue excision and flexor-pronator reapproximation for medial
epicondylitis. [31]
Technique:
With the patient supine and the arm resting on an arm board, a tourniquet is applied. An
8- to 10-cm incision is centered over the medial epicondyle. The common flexor origin is incised
sharply and reflected with care not to violate the medial collateral ligament.
The position of the ulnar nerve is noted, and the nerve is protected throughout the procedure.
The pathologic tissue is identified on the undersurface of the flexor pronator mass and excised
The underlying medial epicondyle is debrided of soft tissue, and multiple small holes are drilled
to create a vascular bed. The common flexor pronator origin is then reattached to this bleeding
surface with interrupted absorbable sutures. After appropriate subcutaneous and skin closure, a
molded posterior plaster splint is applied. Sponge-squeezing and wrist and hand range-of-motion
exercises are initiated immediately. The splint and skin sutures are removed 7 to 10 days
postoperatively. Gentle passive and active elbow, wrist, and hand range-of-motion exercises are
encouraged. Resisted wrist flexion and pronation exercises are initiated at 4 to 6 weeks, followed
by a progressive strengthening program. Return to activity is generally attained by the fourth
postoperative month. [31]
Physiotherapy Management

35

The orthopaedic surgeon may recommend that the patient with golferelbow receive physical or
occupational therapy. The discipline of therapy usually depends on the type of facility available,
the accessibility of therapists, and physiotherapist preference. The proper means of treatment for
golfers elbow are discussed below, in the Occupational Therapy section: [32]
Electro Therapy
Interferential Therapy:
This one requires pads stuck to your arm and the frequency sweep artificially activates your
muscles, Lots of tingling and making my whole arm twitch and move, it was quite
uncomfortable at points. Very odd and very strange, there was definite movement of the elbow
components, once can only hope that was a good thing. I had 5 x 10 min treatments of this over 5
weeks, at the same sessions as the Ultrasound.[46]
Ultrasound therapy:
Ultrasound therapy is a one of the most effective treatment of the golfers elbow
condition.
"Pulsed" mode Ultrasound therapy with on to off ratio of one to four (1:4) and a frequency of 1
MHz It was given in contact, using Electro Medical Supplies' ultrasonic coupling medium. The
space averaged intensity was increased from 1 to 2 W per cm2 and treatment time
was five to ten minutes during the course of treatment. Twelve treatments were given three
sessions per week over four weeks.[46]

36

Figure 2.11: Ultrasound therapy

Transcutaneous Electrical Nerve Stimulation:

TENS is assumed to achieve analgesia through stimulation of afferent peripheral nerves
and the subsequent activation of the pain gate mechanism within the spinal cord and the
descending pain inhibitory mechanisms including endogenous opiates in the spinal cord and
brain stem.[37,38] Explicit anti-inflammatory action is not widely acknowledged, although some
people have argued that TENS may affect local tissue healing.[48]

37

Figure 2.12: Application of TENS electrode

We selected the TENS dose (based on parameter selection, stimulation time, and
frequency) on the basis of our previous laboratory work,[49-50] the findings of which are confirmed
in more recent literature.[51-52] This dose is most likely to achieve analgesia and comprises
asymmetrical biphasic waveform, continuous high frequency (110 Hz) stimulation, with a pulse
duration of 200 s (all of which were pre-programmed and fixed by the manufacturer within the
TENS unit), and intensity (ma), which the participants selected as a tolerable very strong
tingling/buzzing sensation without this being painful. Two electrode pads were applied to the
medial aspect of the elbow and forearm. Participants were advised to use the TENS machine for
a minimum of six weeks when their pain was present. They were provided with a trial specific

38

booklet regarding the use and maintenance of the machine and electrodes, in addition to
instructions on how to apply the TENS at home.[51-52]
Exercise Therapy:
Treatment begins with rest, ice, compression, and bracing, to decrease pain and inflammation.
One to 6 weeks of relative rest of the affected muscles and tendons is typically advised, until
discomfort subsides. Icing is employed for 5-10 minutes, 4-6 times per day and is particularly
important if a patient presents after an acute event. Patients should be instructed to avoid icing
over the ulnar nerve. [32]
Compression with a medial counterforce brace (i.e., a tennis elbow splint) with a pad placed
anteromedially on the proximal forearm over the flexor-pronator mass is routine. Discontinue if
symptoms of an ulnar neuropathy worsen. In addition, if the symptoms are severe, brace with a
wrist splint worn in the neutral position in order to rest the wrist flexors. In milder cases, a
counterbalance brace may be used alone instead of a rigid splint; this limits extremes of motion
while allowing some movement for functional activities. In the case of ulnar nerve involvement,
a nighttime elbow extension splint should be considered. The splint is made in 30-45 of elbow
flexion. A daytime elbow pad also may be useful, by limiting additional trauma to the nerve.[32]
After the patient's initial discomfort has subsided, a rehabilitation program with an occupational
therapist should be initiated for muscle/tendon reconditioning. Begin with gentle stretching and
add gradual strengthening of the flexor-pronator muscles, as the patient tolerates. Follow this
with functional activities and with patient education aimed at avoiding re-injury.

39

The patient should be advised to perform very slow stretching exercises 10-15 times to warm up
muscles and increase flexibility, before doing any strengthening exercises or functional activities.
Strengthening begins slowly with isometrics and progresses to eccentric exercises (see the
images below), with a gradual increase in resistance. Take care to cut back on exercises if they
cause a recurrence of symptoms. Icing for 5-10 minutes after exercise is reasonable, especially if
the patient reports pain in the affected area following exercise. [32,33]

Figure 2.8: Strengthening eccentric exercises

A: starting position
Strengthening exercises are performed once pain has subsided with active range of
motion. The starting position (slight pronation) of an eccentric exercise for medial epicondylitis
is shown. In order to prevent further injury, a trained therapist should instruct patients in

40

exercises to confirm proper weight and technique. (The X indicates the medial epicondyle).

Figure 2.9: Strengthening eccentric exercises

B: End position
The eccentric exercise proceeds until full supination has been reached.
Concomitant modalities may include ultrasound, iontophoresis, phonophoresis,
transcutaneous electrical nerve stimulation, and low-energy, extracorporeal shock-wave therapy.
Successful relief from symptoms is variable. Shock-wave therapy has been shown to be less
effective for ME than it is for LE.[32,33]

41

Arm brace A tennis elbow brace or strap applies pressure to the muscles of the forearm,
reducing pressure on the injured tendon in the elbow. You can use the brace or strap while
working or playing sports. Apply the brace so that the cushion is resting on your forearm
muscles, about 3 to 4 inches (10 cm) from the tip of the elbow bone. You may need to wear the
brace for up to six weeks. Avoid wearing a wrist splint (which prevents your forearm from
moving). [33]
Flexibility exercises Flexibility exercises can help to improve your arm's strength and ability
to move.
Golfer's elbow Stand at arm's length away from a wall, with the affected arm closest to the
wall. Place the palm against the wall with the fingers pointing down. Apply gentle pressure to the
hand. Hold for 30 seconds; repeat three times. Perform this stretch daily. [33]
Strengthening exercises A special type of strengthening exercise, known as eccentric
strengthening, is the most effective way to treat elbow tendinopathy. Patients can start these
exercises once their flexibility has improved and they have little or no pain when performing a
strengthening exercise. Eccentric strengthening involves working the affected wrist extensor
tendon and muscle while they are lengthening. Patients can use a weight, elastic band, or a
specially designed rubber bar to do these exercises, and they may be done under supervision or
independently. Eccentric training was superior when compared to other types of strengthening [34]
Eccentric exercise training programme:
1. Warmup of the forearm flexor and extensor muscles by wrist movements without load (12
min) followed by static stretch of the wrist flexor muscles (3 times 3045sec each).

42

2. Eccentric exercises of the forearm flexor muscles. Patient sits next to a table on which the
forearm is resting in full supination and the elbow flexed at about 90o, the wrist slightly flexed
with the palm over the edge of the table facing the ceiling and holding a refillable dumbbell.
Over 57 s, the weight is slowly lowered by dorsiflexion of the wrist. The hand with the weight
is brought back to the starting position with the help of the other hand. Three sets of 5 repetitions
are performed.
3. Static stretch of the wrist flexor muscles (3 times 3045 sec each). To be performed once a day.
Starting weight: 1.0 kg (men), 0.5 kg (women) with 10% weight increase each week for 3
months.
No pain should be experienced during the exercise.
Golfer's elbow Golfer's elbow is treated with eccentric flexion exercises. You should expect to
feel some mild discomfort with these exercises. If the pain becomes sharp or is more than
moderate, stop the exercise and rest for two to three days. Restart with a lighter weight or fewer
repetitions.[34]
Sit with your arm supported (on a table) at shoulder height. The back of your hand should face
the floor, and your hand should hang off the table. Start with your elbow bent, which is less
painful, then progress to keeping your elbow straight. Hold a 1 pound weight in the hand. Using
the unaffected hand, lift the hand with the weight toward the body (keep the arm flat against the
table).
Move the unaffected hand away, and slowly allow the affected hand (with the weight) to drop.
Repeat 15 times, then rest one minute. Repeat two more times. Perform five times per week.

43

After one week, try to lift the hand with the weight without assistance. Increase the weight by 1
to 2 pounds per week. Do not increase the weight unless you can complete 15 lifts.
Kinetic chain If you play a sport that requires arm strength (such as tennis or golf), hold a 1 to
2 pound weight in your hand and reproduce the wrist and elbow motions of your sport. At the
same time, brace your lower body and core (back and abdomen) muscles.[34]
Then, replace the weight with a golf club or tennis racket and practice your swing (without the
ball). If you do the exercises incorrectly, you may feel more pain. If you have pain with
strengthening exercises, consider seeing a rehabilitation specialist, such as a physical therapist or
athletic trainer, to help supervise your recovery.
When will I feel better? Most people respond well to treatment. You might have some pain
during work or sports for up to 6 to 12 weeks. Some people will need formal rehabilitation with a
physical therapist.
If your pain persists, an injection into the painful tendon might help to relieve pain. In addition,
there are many new treatments being developed to promote tendon healing, such as using blood
products, shock wave therapy, acupuncture, and nitroglycerin patches. Surgery is not usually
needed unless symptoms have not improved after six or more months of treatment. [34]
Cyriax Technique
Cyriax and Cyriax35 claimed substantial success in treating Golfers elbow using deep transverse
friction (DTF). For it to be considered a Cyriax intervention, the two components must be used
together in the order mentioned. Patients must follow the protocol three times a week for four
weeks.35,36 Deep transverse friction Although the word friction is technically incorrect and would

44

be better replaced by massage,this name will be used in this article. DTF is a specific type of
connective tissue massage applied precisely to the soft tissue structures such as tendons. It was
developed in an empirical way by Cyriax and Cyriax and is currently used extensively in
rehabilitation practice.3740
It is vital that DTF be performed only at the exact site of the lesion, with the depth of friction
tolerable to the patient.35,36,38, 40 42 The effect is so localised that, unless the finger is applied to the
exact site and friction given in the right direction, relief cannot be expected. 35,36 40 42 DTF must be
applied transversely to the specific tissue involved, unlike superficial massage given in the
longitudinal direction parallel to the vessels, which enhances circulation and return of fluids.35
The therapists fingers and patients skin must move as a single unit, otherwise subcutaneous
fascia could lead to blister formation or subcutaneous bruising.40
As a general guideline, DTF is applied for 10 minutes after the numbing effect has been
achieved, every other day or at a minimum interval of 48 hours, because of the traumatic
hyperaemia induced, to prepare the tendon for the manipulation. 35,36,38,40,42 There is only empirical
evidence to support the times suggested above. Unfortunately, the technique has developed a
reputation for being very painful.41,43,44
However, pain during friction massage is usually the result of a wrong indication, a wrong
technique, or an unaccustomed amount of pressure. If this form of massage is applied correctly, it
will quickly result in an analgesic effect over the treated area and is not at all painful for the
patient.35,36,40,42 On the other hand, treating clinicians claim this technique places considerable
strain on their hands.38,44

45

Stretching Exercise:

Figure 2.10: Stretching Exercise

Here was the first exercise I tried, designed to stretch the epicondyle tendons: place your
hands flat on a table, twisted 180 degrees to the outside so that your fingers are pointing at your
body. (So twist your right hand clockwise, and your left hand anti-clockwise.) Make sure your
whole hand is flat on e tension right is tricky: just tight enough so that it doesnt fall off, but not
so tight that it pinches. The issue of course is that the cross section of your forearm changes,
depending on what youre doing with the table, from fingers to the heel of your palm. Now by
leaning back away from the table, you will feel your whole forearm muscles and tendons stretch.
Stretch them as much as you can comfortably do and hold for 30 seconds. I did this 5 times a day
for several months (both arms for consistency and a control test).[34,45]

46


stretching training programme
1. Contraction of the forearm extensors (10 s)
2. Relaxation (2 s)
3. Stretching (1520 s)
4. Repeat 35 times.
To be performed twice daily
Forearm Band
I wore it list this for several weeks, then back on the forum, one whod recommended it
said it only started to make a difference for him when he started wearing it 24/7. So I started
wearing it at night too. That took a LOT of getting used to, but I did wear it day and night for
about 2 months in total.
Band is meant to work is still out for debate, Ive heard 2 explanations: A) It relives the
pressure on your tendons, allowing it to heal. B) It constantly stretches your tendons (seeming
the polar opposite to (A)) which means that normal use is easier. All I can say is, it was around
the time that I started wearing it day and night, that I first started to notice an improvement in my
elbow. Not much, but some. Each week didnt seem to hurt quite as much as the last. It was late
March I think and I had started to turn the corner.[45]

47

Home based Exercise Program

1. Along with keeping up with the stretching, the 3rd physio gave me a list of exercises to do twice a
day. The regime was this:
2. Heat the elbow with a wheat bag for 10 minutes.
3. With an empty dumbbell bar (weights 1.5kg) do 10 palm up wrist curls, with back of forearm
resting on your leg and hand jutting out past your knee.
4. Reverse the hand so palm is down, and do 10 reverse wrist curls i.e. back of hand is raised, again
forearm rests on leg.
5. Keep the arm resting on your left, grasp the dumbbell bar at one end, and tilt the bar back and
forth from the horizontal on the left, through 180 degrees, to the horizontal on the right, and
return. Do that 10 times.
6. Setting the dumbbell bar aside, form a circle with the tips of your fingers (make your hand like a
claw) and wrap an elastic band around the outside of your finger tips. Now try to stretch the
elastic band by spreading your fingers out wide, maintaining the circular shape. Do this 10 times.
7. End by cooling the elbow with an ice cube.
8. These exercises were tough to start with, but I soon moved up from 2 rounds of 10 of each
exercise, to 3 rounds of 10, then 3 rounds of 15, all twice a day still. I also did all this with my
good left arm too, partly as a control test and partly so that I was exercising my body evenly. I
actually soon ditched the final icing of the elbow, which was far too uncomfortable, with a 2nd
heating with the wheat bag.
9. These exercises were done twice a day all through April and May. I also added another once I
had worked up to 3 x 15 of each:
10. Tie some string round the middle of the dumbbell bar and wind up about a meter of it, like a yoyo. At the other end, tie a weight. I used a 1.25 kg weight and that was more than enough!
11. Grab the dumbbell bar at each end with both hands, and just by moving your wrists, unwind the
weight (you may need to stand for this) until all the string is paid out and the weight is at the
bottom.

48

12. Now keep winding with your wrists in the same direction so that the string winds on the other
way and the weight rises up from the floor to your hands. This is surprisingly hard!
13. Finally reverse the process completely.
14. Do this for every round of the above set of exercises, so 3x in total, twice a day.[45]

49

CHAPTER- 3
CASE STUDY

Name: XYZ
Age: 40

Weight: 50 kg
Height: 149 cm

Sex: MALE
Date: 15/02/16

50

Occupation: CARPENTER

Address: KHURRAM NAGAR, LUCKNOW

Chief complains: Patient complains of pain at the medial side of the elbow since last 15
DAYS
History:
History of Present illness:
As patient stated that he was apparently normal almost a month before with out any
difficulty in performing the work which he used to do in his job but from last 3 week the pain
gradually started developing which was unnoticed. Thereafter he stopped the work and back to
home and applied local oil massage and took the hand in resting position to subside the pain.
Next day he approached to local physician and advised to take rest for few days along with
some medication. But as such intensity of pain was not controlled and he was not able to do his
manual work of carpentary and finally he came to orthopaedic department where the refered
the case to physiotherapy department.

Personal History: Tobacco

Family History:

51

Parents brother

Occupational history:

No Significance

Intensity of work:
o Moderate
Working hours: 14-16 hrs
Pain history:
Location of Pain:
Site : Medial Epicondyle
Side : Left Hand

Pain Onset: Sudden

Duration :
Pain duration:
o 12 hrs
Nature of Pain:
o Intermittent
Type of pain:

52

o Localized
Aggravating factors: Hand twisting movement (sweeping,picking up object).
Relieving factors : Analgesic & rest.
Pain on coughing/sneezing: Absent
Intensity of pain:

At Work
0

VAS

10

|-----|-----|-----|-----|-----|-----|-----|-----|-----|-----|

At Rest:
0
VAS

On observation:

53

Attitude :

10

|-----|-----|-----|-----|-----|-----|-----|-----|-----|-----|

Physical Examination:

Normal

Posture:Standing
o Ant view = Normal
o Post view = Normal
o Lat view = Normal
Head:
Shoulder: Normal
Spinal: Normal
Pelvis: Normal
Gait: Normal

Skin colour: Normal

54

On palpation:
Skin:
o warmth
Normal
o texture
`

Tenderness: Grade-2+
Spasm: Absent
Edema: Absent
Trigger points: Absent

On Examination:
ROM:

Movement

AROM

PROM

Elbow Flexion

110

120 to 130

Elbow Extension

110 to 0

120 to 0

Wrist Flexion

50

60

Wrist Extension

60

70

55

MMT:

elbow flexor : 4

Elbow extensor : 4
Wrist common flexor: 3
Wrist common extensors: 3
RESISTED ISOMETRIC TEST : weak and painful

o Elbow joint muscles = 4+

o Wrist flexor muscle = 3+

Differential Diagnosis

Olecranon bursitis.

Elbow arthritis.

Medial epicondylitis

Special Test:
o Reverse cozen test (+ve)

56

o Tinnel test (-)

o Median nerve compression test (-)
Neural Tension Test: (Upper Limb)
o Ulnar Nerve (-ve)
o Radial Nerve (-ve)
o Median Nerve (-ve)

Provisional diagnosis: Based on the following:

Clinical findings

Special tests

Radiological findings The provisional diagnosis is

----------------------???? Medial epicondylitis

MANAGEMENT:
Treatment Protocol:(Physiotherapy)

57

Short Term Goal:

o To decrease pain
o To Maintain ROM
o To Maintain muscle flexibility
o To prevent complication
Long Term goal:
o
o
o
o

To gain maximum ROM

To improve strength
To improve the flexibility
To improve ADL function.

Plan of treatment:
Treatment was given once a day, seven days in a week, for 4 weeks.
Treatment protocols for 0 to 2 week
Ultrasound therapy:
Mode:

Continuous

Frequency:

1 MHz

Intensity:

1.5 W/cm2

Time:

7 minutes

Treatment area:

58

Over medial aspect of elbow joint.

Total area:

10 cm2 (approximately)

Exercise:
1. Stretching exercise for 10 repetitions.
2. Strengthening exercise for 10 repetitions.
3. Deep friction massage for 10 mints.
Home advice:
1. Heat the elbow with a wheat bag for 10 minutes.
2. With an empty dumbbell bar (weights 1.5kg) do 10 palm up wrist curls, with back of forearm
resting on your leg and hand jutting out past your knee.
3. Reverse the hand so palm is down, and do 10 reverse wrist curls i.e. back of hand is raised, again
forearm rests on leg.
4. End by cooling the elbow with an ice cube.
At the end of first week a full assessment was done in which pain reduced from 6 to 4 on VAS at
work and rest 4 to 2.
Treatment protocols
for 2 to 4 weeks:
Ultrasound therapy:
Mode:

Continuous

Frequency:

1 MHz

Intensity:

1.5 W/cm2

59

Time:

7 minutes

Treatment area:

Over medial aspect of right elbow joint.

Exercises:
1. Heat the elbow with a wheat bag for 10 minutes.
2. With an empty dumbbell bar (weights 1.5kg) do 10 palm up wrist curls, with back of forearm
resting on your leg and hand jutting out past your knee.
3. Reverse the hand so palm is down, and do 10 reverse wrist curls i.e. back of hand is raised, again
forearm rests on leg.
4. End by cooling the elbow with an ice cube.

At the end of third week a full assessment was done in which pain is reduced from4 to 3 on VAS
at work and rest4 to 2.

60

CHAPTER-4
CONCLUSION

CONCLUSION

The result concluded that modalities like Ultrasound, and manual therapy including
stretching, strengthening cyriax technique. Have played a significant role in decreasing pain, in
case of medial epicondylitis, thereby they helpful in rehabilitating patients to daily life activities.

61

I found decrease in pain from 6 to 3 on VAS at work in case of Golfers elbow within 4 weeks
treatment protocol.

62

CHAPTER-5
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CHAPTER-6
APPENDICES

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APPENDIX-A
VAS SCALE

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VISUAL ANALOGUE SCALE (VAS)

Pain was measured by Visual Analogue Scale (VAS) ,which seems to be most sensitive
amongst other means of measuring pain. At the same time its reliability and validity has
been proven Clarke and Spear has proved the reliability sensitivity of VAS.VAS consists
of 10cm long straight line drawn on a paper with 0 (no pain) at the extreme left 10 (worst
pain) at extreme right .Subject were initially educated about the scale and then asked to
mark on the scale according to the level of pain.
Where,
0 = No pain
1 = Very mild pain
2 = Mild pain
3 = Moderate pain
4 = Fairly severe pain
5 = Very severe pain
6 = Intense pain
7 = Very intense pain

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8 = Incapacitating pain
9 = Worst pain
10 = extensively worst pain

APPENDIX- B
CONSENT FORM

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CONSENT FORM FOR THE PATIENT

I..voluntary consent to participate in the research

study
..

The

researcher has explained me the diagnostic and treatment approach in detail along with the risks
of participation and answer all my questions related to the research to my satisfaction.

Signature of the participant :

Residential address :
Phone No :
Date :

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