Golfer's elbow (medial epicondylitis): how it differs from tennis elbow and the state of the evidence for treatment

The difference between golfer's elbow and tennis elbow

Both conditions are overloading of the tendon attachment sites at the elbow, but the location and the strained movement differ:

So golfer's elbow actually concerns a far broader group than golfers; its name is misleading.

Who gets it?

• Manual and repetitive force-requiring occupations: In workplace studies, the most consistent risk factor has been found to be forceful (force-requiring) work; interestingly, it has not been clearly demonstrated that repetitive movement alone constitutes an independent risk. Among worker populations, a frequency of around 4-5% has been reported.
• Throwing and racket sports: Sports that place repetitive inner strain (valgus load) on the elbow, such as baseball pitching, javelin, golf, and tennis (especially with poor technique).
• Weight training: Heavy gripping, biceps/forearm work, and pulling movements with faulty technique can strain the inner tendons.
• In the general population the typical age is between 40-50, and women and men are affected roughly equally.

The natural course is mostly benign: in a study of a worker population, the recovery rate over 3 years was found to be approximately 81%.

Why is it important to distinguish ulnar nerve involvement?

On the inner side of the elbow, the ulnar nerve passes through the channel (cubital tunnel) right next to the epicondylitis. If this nerve is compressed or irritated, it causes inner-elbow pain similar to golfer's elbow; but in addition there is numbness-tingling in the ring and little fingers, weakness in the hand, and loss of dexterity. Ulnar nerve involvement can coexist with golfer's elbow; if there is numbness in the ring and little fingers or weakness in the hand, this should be evaluated separately.

The distinction is important because:

• A pure tendon problem is resolved with load management and exercise.
• If there is significant nerve involvement, the treatment and, if necessary, the surgical plan change; tendon exercise alone is not enough.

Differential diagnosis: the tendon is not the only cause of inner-elbow pain

Other conditions that must be considered in pain on the inner side of the elbow:

• Medial collateral ligament (ulnar collateral ligament) injury: Especially in baseball pitchers and throwing athletes. The pain is slightly lower than the tendon attachment site, over the ligament; there is pain during throwing and sometimes a "tearing/pop" sensation. On examination, the "moving valgus stress test" and the "milking maneuver" are used. This is a serious diagnosis that can affect an athletic career and must be distinguished from tendinopathy.
• Ulnar neuropathy (cubital tunnel syndrome): As described above, it presents with numbness and loss of strength in the fingers.
• Nerve compression originating from the neck (C8-T1) and problems within the elbow joint itself (cartilage, arthritis) can also refer pain to a similar area.

For this reason, the diagnosis is not made merely by saying "inner-elbow pain"; the examination, and if necessary ultrasound or nerve conduction study, are evaluated as a whole.

Treatment: the evidence is weaker than for tennis elbow

The most honest statement about golfer's elbow treatment is this: there are few well-designed randomized studies specific to this condition. Most recommendations are adapted from tennis elbow, which has been studied far more. Nevertheless, the available knowledge supports the following framework:

• The first step is conservative, and most patients respond. The load/activity that triggers the pain is regulated (not completely quitting work or sport, but adjusting the dose).
• Graded strengthening exercise (eccentric-weighted programs) is central to treatment. Reviews specific to golfer's elbow show that pain can decrease and function can increase after exercise; however, these findings rely largely on within-group improvement (the difference before and after treatment), and because of the scarcity of comparative studies, the evidence for the causal efficacy of exercise is weak. The number of studies is small, the samples are small, and the quality of evidence is low; part of the observed improvement also overlaps with the naturally good course of these conditions. This approach is largely adapted from the stronger evidence in tennis elbow.
• Supports such as a wrist splint/brace, ice, and painkillers may relieve symptoms in the short term but are not curative on their own.

The state of the evidence for injections

• Cortisone (corticosteroid) injection: A randomized study conducted in golfer's elbow (Stahl et al.) showed that the injection provided additional pain reduction only in the first 6 weeks and that its superiority over placebo (saline) was lost from the 3rd month onward. So cortisone provides temporary relief but is not a long-term solution; moreover, because of concern about weakening the tendon, repeated injections are avoided.
• Platelet-rich plasma (PRP): The overwhelming majority of PRP studies have been conducted in tennis elbow; data specific to golfer's elbow are limited and of low quality. Some small studies suggest that PRP may yield results similar to surgery, but these data must be interpreted very cautiously because of selection bias and confounding factors. There is no strong evidence routinely recommending PRP for golfer's elbow.

When does surgery come onto the agenda?

Surgery is generally reserved for selected, refractory cases that do not improve despite 6-12 months of properly applied conservative treatment. In the decision to operate, whether there is accompanying ulnar nerve involvement matters; it is evaluated separately and, if present, broadens the surgical plan — though it is not itself an indication for tendon surgery. Although surgical outcomes are generally reported as good, the decision is individual and should be supported by good rehabilitation.

For clinicians

Medial epicondylitis is an angiofibroblastic tendinosis of the flexor-pronator origin, primarily the pronator teres and flexor carpi radialis; the histopathology parallels the lateral side, which is why the terminology "tendinopathy/epicondylalgia" is preferred. The asymmetry of the evidence base is a critical point: while systematic reviews find numerous RCTs for lateral epicondylitis (in one review all 20 RCTs were lateral), the number of RCTs specific to the medial side can be counted on one hand (an eccentric exercise review had n≈143, 5 studies, low certainty). Therefore the recommendation of exercise-based load management is largely extrapolation — this uncertainty should be conveyed to the patient explicitly. For corticosteroids, the Stahl et al. data are classic: significant superiority at week 6, equalizing with placebo at month 3 and year 1; this supports the message of "temporary analgesia, not a cure." In the differential diagnosis, the priorities are ulnar neuropathy (cubital tunnel) and UCL pathology; the anatomical proximity of the medial epicondyle origin with the UCL and the course of the ulnar nerve makes distinction by palpation difficult. In the throwing athlete with medial pain, UCL should be ruled out with the moving valgus stress test (O'Driscoll) and the milking maneuver, and if necessary dynamic/valgus-stress ultrasound or MRI should be considered. Accompanying ulnar neuropathy must always be inquired about at the outset; however, ulnar neuropathy is evaluated primarily clinically. Electrophysiological study is helpful in diagnostic uncertainty, in grading severity, or in surgical planning, and may come back normal in mild cases; therefore a normal result does not exclude the diagnosis. Tendinopathy and cubital tunnel pathology should be evaluated separately: the coexistence of ulnar neuropathy is not by itself a surgical indication, but recognizing both conditions affects both the conservative response and the treatment plan.

Frequently asked questions

Related articles

• Tennis elbow: why is cortisone a trap, and why is wait-and-see reasonable?
• PRP and injection treatments: when do they work, and when don't they?

Scientific references

This information is for general guidance only; it does not replace an examination, a diagnosis, or your physician's individual advice. Please consult a physician for your symptoms. About the author: Doç. Dr. Oğuz Yüksel — Academic Profile.