Epitrochleitis (golfer's elbow)

Synonyms

• Medial elbow tendinitis
• Epitrochleopathy

What is the difference between epitrochleitis and epitrochleopathy?

Epitrochleitis and epitrochleopathy often refer to the same pain in the tendons on the inner side of the elbow, without indicating whether inflammation is present. Tendons connect muscles to bones. The term tendinopathy describes persistent pain in the tendon and difficulty using it when it is under stress.¹

Inflammation is the body’s defense and repair response. Persistent tendon pain is not always accompanied by the typical inflammatory response following a recent injury. However, more detailed studies have detected inflammatory cells in certain tendons and suggest more subtle mechanisms. Therefore, not all tendon pain can be categorized as either inflammatory or non-inflammatory.^{2, 3, 4}

The term “tendinitis” suggests inflammation of the tendon. The term “tendinopathy” is more general: it does not imply a specific mechanism. The choice of treatment is based on your symptoms, your functional abilities, and the physical examination, rather than on this difference in terminology alone.

In this article, the term “epitrochleitis” refers to pain in the tendons on the inside of the elbow. It does not mean that all elbow pain has the same cause.

What is elbow epitrochleitis?

Epitrochleitis is pain in the tendons on the inner side of the elbow—the tendons of the muscles that bend the wrist, rotate the forearm, and help close the hand.

What is a tendon?

A tendon connects a muscle to a bone and transmits the muscle’s force to produce movement. Several tendons on the inside of the elbow attach to the muscles that bend the wrist or turn the palm downward. This latter movement, called pronation, is involved in certain actions such as screwing something in or pouring. Some muscles that close the fingers also attach to the inside of the elbow.²

Why is it called "golfer's elbow"?

Epitrochleitis is known in English as “golfer’s elbow” because the motions involved in golf place strain on these tendons. Repetitive movements and unusual exertion can contribute to the pain.²

Golf can also cause pain on the other side of the elbow. A 2009 review describes lateral epicondylitis, or tennis elbow, as the most common arm injury among amateur golfers.⁵

The equivalent injury on the outer side of the elbow is more commonly known asepicondylitis, or tennis elbow.

What are the causes of elbow epitrochleitis?

Repetitive movements or an unusual increase in activity can contribute to epicondylitis of the elbow. Movements that involve gripping an object, bending the wrist, or rotating the forearm place strain on the affected tendons.²

Not all pain on the inside of the elbow is epicondylitis. A problem with the ulnar nerve—which runs behind the inner bony prominence of the elbow—or with the nearby ligament can cause similar pain. A ligament connects two bones and helps stabilize their joint. A physical examination helps distinguish between these possibilities; several conditions may also coexist.^{6, 7}

What activities can contribute to pain?

• Repetitive movements of the wrist or elbow
• Overload of the elbow muscles (after a new sport or activity, for example)

Inflammatory arthritis, a condition that causes inflammation in the joints, can also cause pain in this area. This is another condition that must be distinguished from epicondylitis. Learn more about inflammatory pain.

A tendon can become painful when the strain on it exceeds what it can tolerate at that moment. This explanation helps in adjusting activities; however, it does not, on its own, identify the cause of every instance of pain.

What changes in physical activity can put more strain on the elbow?

• Doing renovations all day without being used to it, doing a lot of painting, hammering, or using a screwdriver
• Cooking all day by kneading dough or mixing a lot with your hands (repetitive movements with the hand closing).
• Starting your golf season by increasing the duration or intensity of your practice sessions too quickly

Could this kind of pain be caused by a nerve?

A problem with the ulnar nerve can cause pain near the inner side of the elbow and numbness in the hand. Check out our article on arm neuralgia, a type of nerve-related pain.

What are the symptoms of elbow epitrochleitis?

Symptoms of epitrochleitis include pain on the inside of the elbow—which may extend to the forearm—and difficulty grasping objects. The pain often develops gradually.

The most common symptoms are:

• Specific pain on the inside of the elbow, which often develops gradually
• The pain may radiate down the forearm and into the wrist; pain in the fingers also warrants a check of the nerves
• Weakness and pain when picking up objects (picking up a pot, a coffee cup, a grocery bag)

Pain that radiates toward the shoulder or numbness in the hand also warrants an examination of the nerves and the neck. Brachial neuralgia is a possibility; however, these symptoms alone are not enough to confirm it. Learn more about brachial neuralgia.

How to diagnose elbow epitrochleitis?

A healthcare professional diagnoses epitrochleitis based on the patient’s description of symptoms and an examination of the elbow. In particular, the healthcare professional checks for pain upon pressure and during movement of the wrist or forearm.

Imaging tests aren’t always necessary. They can be helpful if there’s still uncertainty or if another cause is suspected. An X-ray mainly shows the bones; an ultrasound uses sound waves to examine tendons, among other things. The results are explained during the exam. Your physical therapist can refer you for the necessary tests or to other professionals.^{6, 8}

When to consult a physiotherapist for elbow epitrochleitis?

A physical therapy consultation is recommended when pain on the inside of your elbow interferes with your daily activities, persists, or recurs. The physical therapist will assess your symptoms and may refer you to a doctor if another cause is suspected.

In Quebec, you can see a physical therapist directly at a private clinic without a doctor's prescription. However, some insurance plans may require a prescription for reimbursement.⁹

Which symptoms require urgent medical attention?

Arm pain that occurs during physical activity and goes away with rest requires urgent medical attention. The same applies to a swollen arm accompanied by a high fever or sensations of heat, cold, or chills.

Seek care at an urgent care center or the emergency room if your arm is very painful and difficult to move, if an injury is accompanied by a cracking sound or deformity, or if your arm tingles or becomes numb.

Call 911 if you experience sudden arm pain accompanied by pressure, heaviness, or tightness in your chest. Do not wait for a physical therapy appointment.¹⁰

What physiotherapy treatments are available for medial epicondylitis (golfer's elbow)?

Physical therapy treatments for epicondylitis include tailored exercises, pain relief measures, and advice on adjusting your activities. The program takes your challenges and goals into account.⁸

Your physical therapist will assess the following to understand your difficulties:

• The possible ranges of motion in your joints
• How your nerves respond to arm movements, if your symptoms warrant it
• The quality of your movements
• Your strength and your ability to control your arm during exercise

Based on the assessment results, your physiotherapist will:

• Can mobilize your elbow—that is, move it with their hands—to help relieve pain and make it easier to move
• It will provide you with specific exercises to improve control of elbow and wrist movements
• Give you exercises to regain mobility, reduce pain and regain your muscle strength.
• This will help you adjust the duration, intensity, and breaks in your activities so you can gradually resume your routine
• Give you advice for your posture and movements.

A 2014 study followed 20 people whose epicondylitis persisted despite previous treatment. After completing a program combining wrist-strengthening exercises and other physical therapy treatments, their difficulties with daily activities had significantly decreased. The program lasted an average of 6.1 weeks. Since the study did not include a comparison group, it is not possible to attribute this improvement solely to the added exercise.¹¹

What can I do at home for medial epicondylitis (golfer's elbow)?

Home care involves temporarily avoiding movements that are too painful, and then gradually resuming them. Continue with the movements and activities that you can tolerate.

Temporarily limit the most painful movements without completely immobilizing your arm. Then adjust the intensity based on the pain you experience during and after the activity. If the pain increases or remains severe, reduce the intensity and have the program reevaluated. Progress depends on how you respond; there is no requirement to increase the intensity every week.²

A study on the Achilles tendon compared two groups that followed the same exercise program. One group was allowed to continue running and jumping while monitoring their pain; the other group stopped these activities for the first six weeks. Among these 38 participants, both groups made progress, with no clear difference between them. This result supports supervised continued activity in this population; it does not automatically validate the same approach for a painful elbow.¹²

Strengthening exercises can gradually increase the load placed on the tendon. An eccentric exercise involves slowing down the movement as the muscle lengthens. In a 1998 study, 15 people with persistent Achilles tendon pain returned to their previous running level after 12 weeks of this type of training, with less pain and improved strength. Their improvement does not prove that this method is the best for all tendons.¹³

For the elbow, the exercise added in the 2014 study worked the muscles that flex the wrist by slowly holding back the return of a twisted rubber band. The physical therapist can select and adjust the resistance to suit your abilities.¹¹

Understanding your pain and learning how to adjust your activities are part of the treatment. The physical therapist explains the exercises and how to resume your daily activities, then checks how you respond.² The 2018 guidelines on the Achilles tendon also recommend patient education and support. This recommendation pertains to the Achilles tendon and does not, on its own, assess the effect of these explanations on epitrochleitis.¹⁴

When sleeping, try to keep your arm at your side or propped up on a pillow. Avoid placing your arm behind your head or under the pillow if that increases your pain. Choose a position that's comfortable for you.

Here are some other tips that may help relieve the pain:

• A brace worn a few centimeters below the elbow may provide relief for some people during physical activity. Keep wearing it only if it is comfortable and helpful. This support can be part of your treatment; it does not replace all the necessary exercises and adjustments.² Trials included in a 2020 review suggest immediate relief with forearm supports, but the evidence is of low quality and pertains to pain on the outer side of the elbow. Another six-week trial focusing on this side of the elbow found greater pain relief with a splint—a brace that restricts wrist movement—than with a wrist strap, with no clear difference in overall pain and function assessments. These comparisons do not allow for the selection of the best brace for epicondylitis.^{15, 16}
• Try lifting your shoulder slightly before lifting a light load. Only keep this adjustment if it reduces your pain; it isn't necessarily suitable for everyone.

If home remedies don’t help or if the pain returns, see a physical therapist. However, the urgent signs described above require immediate medical attention.

What studies does this article draw on?

This article is based on studies of epitrochleitis, supplemented by research on the lateral aspect of the elbow and the Achilles tendon. Findings specific to each region are distinguished in the text. The numbers refer to the references below.

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1. Scott A, Squier K, Alfredson H, Bahr R, Cook JL, Coombes B, et al. ICON 2019: International Scientific Tendinopathy Symposium Consensus: Clinical Terminology. Br J Sports Med. 2020;54(5):260-262. (Back to section: 1)
2. Reece CL, Li D, SUSMARSKI AJ. Medial Epicondylitis (Archived). StatPearls. 2024. (Back to sections: 1, 2, 3, 4, 5, 6, 7)
3. Ashe MC, McCauley T, Khan KM. Tendinopathies of the upper extremity: a paradigm shift. J Hand Ther. 2004;17(3):329-34. (Back to section: 1)
4. Fredberg U, Stengaard-Pedersen K. Tissue pathology, pain mechanisms, and etiology of chronic tendinopathy, with a special focus on inflammation. Scand J Med Sci Sports. 2008;18(1):3-15. (Back to section: 1)
5. Bayes MC, Wadsworth LT. Upper extremity injuries in golf. Phys Sportsmed. 2009;37(1):92-6. (Back to section: 1)
6. Konarski W, Poboży T, Kotela A, Hordowicz M, Poboży K. Ultrasound in the Differential Diagnosis of Medial Epicondylalgia and Medial Elbow Pain: Imaging Findings and a Narrative Literature Review. Healthcare (Basel). 2022;10(8). (Back to sections: 1, 2)
7. Grana W. Medial epicondylitis and cubital tunnel syndrome in throwing athletes. Clin Sports Med. 2001;20(3):541-8. (Back to section 1)
8. Donaldson O, Vannet N, Gosens T, Kulkarni R. Tendinopathies Around the Elbow, Part 2: Medial Elbow, Distal Biceps, and Triceps Tendinopathies. Shoulder Elbow. 2014;6(1):47-56. (Back to sections: 1, 2)
9. OPPQ. How does it work? (Back to section 1)
10. nhs.uk. Elbow and arm pain. 2017. (Back to section: 1)
11. Tyler TF, Nicholas SJ, Schmitt BM, Mullaney M, Hogan DE. Clinical outcomes of adding eccentric exercises to the rehabilitation of golfers' elbow following previous failed treatments. Int J Sports Phys Ther. 2014;9(3):365-70. (Back to sections: 1, 2)
12. Silbernagel KG, Thomeé R, Eriksson BI, Karlsson J. Continued sports activity, using a pain-monitoring model, during rehabilitation in patients with Achilles tendinopathy: a randomized controlled study. Am J Sports Med. 2007;35(6):897-906. (Back to section: 1)
13. Alfredson H, Pietilä T, Jonsson P, Lorentzon R. Heavy-load eccentric calf muscle training for the treatment of chronic Achilles tendinosis. Am J Sports Med. 1998;26(3):360-6. (Back to section: 1)
14. Martin RL, Chimenti R, Cuddeford T, Houck J, Matheson JW, McDonough CM, et al. Achilles Pain, Stiffness, and Muscle Power Deficits: Midportion Achilles Tendinopathy (2018 Revision). J Orthop Sports Phys Ther. 2018;48(5):A1-A38. (Back to section: 1)
15. Heales LJ, McClintock SR, Maynard S, Lems CJ, Rose JA, Hill C, et al. Evaluating the immediate effect of forearm and wrist orthoses on pain and function in individuals with lateral elbow tendinopathy: A systematic review. Musculoskelet Sci Pract. 2020;47:102147. (Back to section: 1)
16. Garg R, Adamson GJ, Dawson PA, Shankwiler JA, Pink MM. A prospective randomized study comparing a forearm strap brace with a wrist splint for the treatment of lateral epicondylitis. J Shoulder Elbow Surg. 2010;19(4):508-12. (Back to section: 1)
17. Vaquero-Picado A, Barco R, Antuña SA. Lateral epicondylitis of the elbow. EFORT Open Rev. 2016;1(11):391-397.