Tips for general practitioners
Golfers elbow ( medial epicondylitis)
Medial epicondylitis is a common condition which affects the flexor pronator origin. It can occur as a result of repetitive activities or even from a single episode of trauma. The pathologic process behind it is the development of micro tears between the pronator teres and the Flexor Carpi Radialis.
Patients will complain of tenderness over the flexor origin. and weakness with gripping. There is also pain with flexion and pronation thus making it inconvenient to perform most activities of daily living.
Most cases will clear up with activity modification, stretching and NSAIds
Injections for golfers elbow are indicated when there is chronic pain and disability or functional impairment as a result of the pain.
Diagnosing golfers elbow
Most patients will give a history of pain with activity especially lifting and carrying with the affected limb.
Clinical examination will reveal tenderness just anterior to the medial epicondyle. A good provocative test is to get the patient to palmarflex the wrist of the affected limb against resistance. This invariably reproduces the patients symptoms.
See figure 1.
Figure 1.
Technique
Equipment
• Use a 10 mL syringe and a 21-Gauge needle. A 23-Gauge needle is also acceptable.
• Lignocaine can be used safely in dosages of less than 2 mg/kg bodyweight. Generally, 50 mg (5 mL of a one percent preparation) provides adequate analgesia within safe limits.
• Triamcinolone or other steroid preparations are equally acceptable.
• Aseptic techniques should be strictly adhered to.
Landmarks
Identify the medial epicondyle and the olecranon. Next localise the most painful spot. This is usually 1 cm anterior and distal to the medial epicondyle. Take note of the proximity of the ulnar nerve to the medial epicondyle.
Figure 2.
Palpate the medial epicondyle and place your thumb directly on the epicondyle. By staying anterior to the thumb, one can minimize the risk of inadvertent damage to the ulnar nerve. Figure 3
Figure 3.
Keep a thumb on the medial epicondyle and inject 2 to 3 mls of steroid and local anaesthetic. By infiltrating in a small arc, it is possible to maximize the chances of hitting the target area.
Figure 4
Post op advice for patients
• Effects of the lignocaine usually wear off in a few hours. However, the steroid should slowly take effect over the next few weeks.
• Avoid strenuous activity for the following 24 hours.
• If symptoms worsen within the next 2 days, seek medical attention at the clinic. This may be due to a “steroid flare”, which can be managed with cold compresses, NSAIDs and adequate rest.
Contraindications
• Skin abrasions or infections.
• Known allergy to local anesthetics.