Course Instructor (P11)
The elbow permits the movements of flexion, extension, pronation and supination. The golf swing applies specific demands on the elbow. Those demands will vary from lead arm to follow arm. The lead elbow endures most of its stress in the pre-contact phase of the swing, while the follow arm incurs stress while decelerating following the swing.
The elbow joint is an intrinsic collection of bones, muscles, ligaments, and nerves. The humerus has two articulating condyles at the distal end. The proximal end of the ulna forms the olecranon process and is limited in extension bya notch in the humerus. In essence, the ulna works as a stationary axle and the radius turns around it as the forearm and hand rotates. It is the olecranon process that articulates with the proximal radius. Ligaments and tendons use the medial and lateral epicondyles knobs of the humerus as a base of attachment.
The elbow is made up of two joints called the humeroulnar and the humeroradial. The ligament structures which support these joints are the ulnar collateral, radial collateral, annular and the isosceles triangle. The isosceles triangle is comprised of the anterior oblique, posterior oblique, and the transverse oblique ligaments. Flexion and extension of the elbow is controlled by the articulation of the medial condyle with the ulna of the lower arm. The lateral condyle of the humerus articulates with the radius. This articulation is the structure which permits pronation and supination of the lower arm and hand. The medial collateral ligament is attached to the humerus and the ulna. The lateral collateral ligament is attached to the humerus and the radius. The annular ligament binds the radius and the ulna from separating. The movement of the elbow is controlled in the muscles that originate above that structure on the humerus and the scapula. Specifically, the bicep, triceps, and brachioradialis muscles flex and extend the joint. There are numerous muscles that control movements of the forearm, wrist and fingers, these originate at the two epicondyles of the humerus. The bicep muscle conducts flexion and supination of the arm. The triceps muscle extends the forearm and upper arm. The coracobrachialis abducts and assists in flexion and pronation of the arm. The brachialis aids in flexion at the elbow. The anconeus extends the elbow. The brachioradialis flexes the elbow, while supination is controlled by the supinator and pronation by the pronator teres and pronator quadratus.
Olecranon bursitis– most injuries to the olecranon are the cause of a direct blow, but overuse will cause inflammation of the olecranon bursae. Inflammation of the olecranon bursae will significantly impede the ability of the golfer to extend the arm, either during the backswing or in attempting to achieve full extension at the completion of the swing. A quick way to evaluate olecranon bursitis is palpation and observation; one will note a thick and warm feeling at the distal and posterior portion of the humerus. Early intervention will include the use of an elastic wrap, bracing and ice with compression. The chronic presence of olecranon bursitis would require manual massage, heat, active and passive stretching followed by resistive exercises.
Dislocation/Subluxation – commonly, an abrupt stop or hyperextension of the elbow could lead to subluxation or dislocation of that joint. The most common cause of dislocation would be the inability of the upper extremity to bear the full weight of the body upon it in a quick and sustained force. This is not an injury that is common to golf, however golf requires walking long distances on wet or uneven surfaces. Falls commonly result in injuries of this nature. The key component for the clinician is the requirement to rule-out a fracture before attempting a reduction of the displacement.
Epicondylitis – is broken down into either medial or lateral epicondylitis. Medial epicondylitis is most commonly known as pitcher’s or little leaguer’s elbow, while lateral epicondylitis is often called tennis elbow. The golfer is subject to both of these irritations. Full extension at impact will lead to medial epicondylitis while the rotation that occurs at the completion of the swing may lead to lateral epicondylitis. Management of this condition will necessitate limiting pronation or supination. Commonly, a wrap or elastic compressive band is placed around the elbow. Compression often decreases the sense of discomfort, but will provide very little in ameliorating the irritation derived from excessive supination or pronation. It will be necessary to alter the patient’s activities and slowly rehabilitate through the use of exercise bands or resistant training using weights. Sending the golfer back to competition before healing is complete will make the individual susceptible to further injury. The best way to determine when healing is complete is by the absence of pain during stressful activities and by the return of full range of motion, strength, and endurance to the affected muscle groups. Conservative treatment options are the first line therapy in response to this injury. Contrary to popular practice, corticosteroid injections are not considered a first line therapy. This type of treatment can promote collagen necrosis. Phonophoresis and electrophoresis are common therapies proceeding the strengthening and rehabilitative phases. The rehabilitation workout must include antagonistic muscle groups to prevent asymmetry in the strengthening process.
- Compartment Syndrome – look for the five P’s. This would include pain on passive movement with pallor, pulselessness and parasthesias. The key component to this finding is that the pain is disproportional to clinical findings. The fact that there is an impact on neurovascular structures would necessitate a surgical referral, since emergency surgery may be necessary.
- Osteochondritis Dissecans – because this condition occurs secondary to repetitive or compressive trauma, it is important to take this into consideration in the management of the golfer. The amateur golfer not only participates in their sport, but also engages in their work related activities which may lead to cumulative irritation. Osteochondritis dissecans can lead to avascular necrosis of the capitellum. Chronic elbow pain must be taken seriously and compel the clinician to perform appropriate x-rays and direct their assessments towards a differential diagnosis.
- Ulnar Entrapment Syndrome – continual impingment upon the ulnar nerve as it passes through the cubital tunnel on the medial aspect of the elbow can lead to this condition. The patient will most likelypresent with weakness of the grip, pain in the area of the cubital tunnel on palpation and paresthesia of the little finger and the ulnar aspect of the ring finger. Tinel’s sign would be present, further identifying the presence of inflammation of the ulnar nerve. Treatment includes rest, ice, compression, elevation and physiotherapy modalities followed by a resistive exercise protocol.
- There are various tests for ligament stability in the elbow, this includes Valgus or abduction stress to evaluate the medial (ulna) ligament stability. Varus or adduction stress will evaluate the lateral (radial) ligament stability. Tests for lateral epicondylitis would include the resisted wrist extension, resisted long finger extension and palmar flexion/pronation stretch. Testing to evaluate medical epicondylitis consists of resisted wrist extension and wrist extension-supination stretch. To evaluate neurological dysfunction, Tinel’s sign at the elbow would detect inflammation of the ulnar nerve, pronator teres syndrome detects inflammation or entrapment of the median nerve while “pinch grip” detects anterior interosseus nerve dysfunction.