Improving your game, Golfer’s Elbow

Deep wrist pain can be the most common complaint of avid golfers

Acute injuries to the hand are uncommon in golf while development of painful syndromes can be very common, particularly due to underlying arthritis or tendonitis conditions.

Injuries to the upper limb in golfers are of two major types: The less common acute injury from a poor swing, or the much more common overuse injury or exacerbation of an underlying degenerative condition. The latter frequently occurs since golf is predominantly a game with older participants, and players often demonstrate the common pathologies seen in the mature population.

Ironically, many of these problems are seen much earlier due to the unnatural mechanism required in the upper limb during a golf swing. Acute injuries to the hand are uncommon in golf while development of painful syndromes can be very common, particularly due to underlying arthritis or tendonitis conditions.

Carpal Tunnel Syndrome (CTS)

CTS is a common nerve compression disorder at the wrist that can be more symptomatic after a long 18 hole round. Gripping of the club can worsen symptoms typically described as numbness and a cramping feeling in the hand. The golf activity itself, however, does not cause this problem. Initial treatment includes a night splint, high doses of vitamin B6 or anti-inflammatories. A corticosteroid injection in the wrist is occasionally used but the usual treatment is surgical which involves opening the carpal tunnel taking pressure off the nerve. This procedure can be performed through a small incision in the palm or endoscopically. The endoscopic technique implies use of a small fiber optic instrument and local anesthesia with almost no post-op discomfort. An added benefit is that the golfer can get back on the links within a ten to fourteen day period.

Wrist

Deep wrist pain can be the most common complaint of avid golfers. This pain is often ignored by the player or is inadequately diagnosed by the primary care doctor. Evaluation by an orthopedic surgeon is often critical and will consist of a careful physical exam sometimes followed by xrays and even an MRI. However, when a clear diagnosis and treatment plan are not formulated, the player should seek consultation with a hand and wrist specialist. The complex interplay between bony, ligamentous and soft tissue disorders require evaluation by a dedicated specialist and can often save the time and expense of a lengthy diagnostic work-up that may not even be necessary. (Read more detailed information about the three major regions of wrist pain at the Radius web site: www. radthemag.com)

Tendonitis 

Tendonitis of the fingers or wrist usually requires an injection or occasionally a minor surgical release. It can be a very painful condition and should be addressed promptly to avoid developing weakness in the hand and loss of grip strength. Osteoarthritis in the hand can be greatly exacerbated by vigorous gripping as can be experienced in driving a golf ball. The most common locations are the base of the thumb and the last joint of the digits. Mild symptoms can be managed by oral anti-inflammatories but severe pain and occasional deformity is successfully managed using surgical techniques.

Elbow pain

Elbow injuries are much less common than wrist problems but can be much more resistant to treatment. The condition known as golfer’s elbow is a tendonitis of the flexor region on the inside of the elbow. While the name associates the condition with golfing, it is actually relatively uncommon. Treatment usually includes an injection of corticosteroid and therapy for stretching and strengthening of the flexor muscles. While inappropriately named, tennis elbow is much more common in golfers. This painful condition tends to be persistent and leads to more pain when the athlete tries to extend the elbow, which can lead to limitations in long driving shots where power and good follow-through are necessary. Treatment includes intermittent injections but it is preferable to avoid more than three injections because tendon weakening can be a side effect. Resistant cases may require surgical treatment that has traditionally been done with an open incision and potentially long recovery time. Arthroscopic techniques are now also possible in the elbow and allow for very rapid recovery. Newer technology using radio frequency waves to dissolve the painful inflammatory tissue are also possible.

Shoulder Pain 

Deep persistent pain in the shoulder can affect both young and older golfers alike. The causes, however, can be very different and require a thorough diagnostic process to understand the underlying problem and lead to a solution. Young, active patients often feel that their pain is due to overuse. This may be the case, but it is important to understand why. Current exercise regimens usually emphasize strengthening the deltoid muscles, but the rotator cuff is largely ignored. This practice leads to an instability syndrome that can cause pain and even worse, a mechanical deficiency of the shoulder joint. If shoulder pain is a chronic problem, with no history of a single traumatic event, the patient will usually respond to strengthening therapy that requires diligence on the part of the patient and therapist. 

The most common cause of shoulder pain in older athletes is known as impingement syndrome. Bursitis is often an element of this syndrome and this frequently used term is much more accurate in depicting the problem than the term “arthritis.” Impingement occurs when the overlying bony arch of the shoulder is pressing on or irritating the underlying rotator cuff tendons and bursa. This situation may respond to conservative treatment including a cortisone injection to reduce the bursitis and shoulder therapy to improve the strength of the intact rotator cuff. A complete rotator cuff tear implies that the torn tendon has pulled away from the bone and cannot stabilize the head of the humerus against its cup joint. The patient either will be unable to raise the arm or will be able to only with severe pain. This whole range of impingement problems is characterized by pain with elevation of the arm, pain worse at night, and inability to lie on the side of the affected shoulder. Once the pain is severe enough and does not respond to therapy and other conservative means, surgery is indicated. Some smaller tears can be repaired through arthroscopic means. Most repairs require a onemonth period of immobilization in a sling and several months of postoperative therapy closely directed by the surgeon. The shoulder is a demanding joint and requires patience on the part of both patient and treating surgeon.

Prompt attention to painful conditions of the upper limbs will get you back on the greens and will extend your years of playing time at the game you love. 

Dr. Badia obtained his medical degree at New York University and also completed a Hand and Upper Extremity Fellowship at Allegheny General Hospital in Pittsburgh, Pennsylvania. He is the founder of Badia Hand to Shoulder Center, located in the heart of Doral, Florida.