What is Golfer's elbow?

Golfer’s elbow also known as medial epicondylitis is a painful condition involving the common flexor tendon on the medial (inner) area of the elbow. This results from overuse or repetitive use of forearm pronation and wrist flexion.¹ 

What is extracorporeal shockwave therapy (ESWT)?

Extracorporeal shock waves are used in therapy in the form of quick acoustic (sound) waves focused on certain areas in the body to reduce pain and encourage healing through mechanotransduction. This is considered to be efficient, inexpensive and time-efficient.²

Understanding golfer's elbow 

Causes 

Medial epicondylitis, which is associated with excessive activities involving high force, can be prevalent among athletes in golf, tennis, football and throwing sports. It commonly occurs in pitchers and golfers, during a certain phase of their swing or throw. In contrast, more than 90% of disabling cases result from non-sport activities and occupations that demand repetitive exertion and overuse, such as carpentry, plumbing, mason, and construction work.³

Risk factors

Risk factors for golfer's elbow (medial epicondylitis) can be categorised into three areas: athletic, work-related, and general factors. 

In athletes, the following factors¹ can be considered to be contributory to golfer’s elbow training errors 

• biomechanical errors 
• improper equipment 
• functional abnormalities such as lack of strength, low endurance or poor flexibility

Work-related risk factors⁴ are

• Labor-intensive work like lifting, carrying, walking climbing
• Forceful and repetitive movements 
• obesity 
• coexisting conditions 
• work stress

General risk factors¹ are

• Smoking
• Type 2 diabetes

Symptoms 

Golfer’s elbow causes pain and tenderness of the medial (inner) part of the elbow to worsen gradually. There could also be slight signs of inflammation and redness. Initially, the movement of the forearm is free, but later the movement can be limited. Weakness of the forearm may also occur. These signs may impact the quality of life of people having golfer’s elbow.⁵

Mechanism of extracorporeal shortwave therapy (ESWT)

Working of ESWT

Shock waves may be defined as sudden disturbances expressed as high-pressure waves travelling at a velocity higher than sound through a particular medium. Although it is not fully understood how they work to provide therapeutic benefits, it is known they have two main phases: A short burst of pressure increase that takes a maximum of 10 nanoseconds and is then followed by a phase of negative pressure that withstands for a few milliseconds. This process forms tiny pockets of air known as acoustic cavitation, which probably is central to the shockwave’s impact.²

Types of ESWT

There are two types of shock waves. 

• Focal shock waves are created using special devices (electrohydraulic, piezoelectric, or electromagnetic generators) and have a positive and negative phase. These waves reach deep into the tissue with high intensity for targeted treatment
• Radial waves are lower-intensity waves made by a pneumatic (air-powered) device and have only a positive phase. Their strongest point is at the surface, where the applicator touches the skin²

Biological effects of ESWT on tendons

When shock waves are applied, they release energy as they move through tissues with different densities. This energy activates processes that help repair tissue. The therapy can relieve pain, support bone growth, and promote tissue repair through various mechanisms that may help heal the damaged tendons associated with the golfer’s elbow.²

The procedure of ESWT for golfer’s elbow

Preparation  

People with golfer’s elbows taking ESWT should receive clear and well-documented guidance before starting the treatment. The doctor will explain that the treatment's effects may take weeks to appear. They will be informed about the risk of tendon damage, particularly if they have previous tendon issues or return to sports too early after the treatment.⁷

Patient assessment

• Before applying ESWT the physician will undergo a physical checkup to ensure the correct diagnosis and determine the location and degree of the golfer’s elbow. This may require a physical examination, a patient history and some occasions involving imaging that will show exactly where the tendon is damaged
• A radiologic examination can confirm the diagnosis of medial epicondylitis (golfer’s elbow)

Although radiographs in most cases are unremarkable, ultrasonography can be a cost-effective diagnostic tool in showing features of common flexor tendinosis and pathologic change. This helps rule out other causes which may mimic muscle and tendon presentation. This assessment enables the provider to decide on the right treatment plan and determines the suitability of ESWT.⁸

Treatment Protocol

A usual course of treatment consists of up to five sessions that focus on targeting the inner elbow. Each session is spaced 1 to 2 weeks apart depending on the type of device used. The energy level is adjusted based on the patient's pain tolerance and the device technology.⁷

Post-treatment 

Avoid any activities that could trigger problems. If needed, refrain from sports for 4 weeks, with a return to sports based on individual recovery needs. A follow-up to assess clinical success should be done after 8 to 12 weeks.⁷

Benefits of ESWT for golfer’s elbow

• Pain reduction: ESWT can greatly inhibit pain signals since it has the ability to stimulate nerve receptors of the area treated and thus reduce pain sensation
• Improved healing and tissue regeneration: By increasing blood flow to the affected area, ESWT encourages the delivery of oxygen and nutrients essential for tissue repair. It also activates the body’s natural healing mechanisms to repair damaged tendons⁶
• Non-invasive and drug-free: ESWT is a great approach since it is non-surgical with few or no complications and does not require drugs. Therefore, it is a better long-term treatment to help manage the condition

Effectiveness and evidence for ESWT in Golfer’s elbow treatment 

Clinical research and studies

Research focused on extracorporeal shockwave therapy on patients with Golfer’s Elbow (medial epicondylitis) and found a significant decrease in pain and significant improvements in function.⁹ One study compared the effectiveness of focal ESWT with radial pressure wave therapy and concluded that combining both produced a better outcome than using focal ESWT alone because of a higher degree of improvements in pain and function in the short to mid-term​.¹⁰

Factors influencing effectiveness

Although the outcome may differ with the condition’s severity and patient compliance, ESWT remains an effective treatment option, especially in chronic cases and when other forms of treatment have been insufficient.

Side effects, contraindications and limitations of ESWT for Golfer’s Elbow

Common side effects 

Reddening of the skin, pain and bruising (hematomas) are some side effects that usually occur during and after treatment. However, redness is considered harmless and never requires stopping the treatment. In the future, it is important to consider the possibility of triggering migraines and the potential risk of dizziness when using ESWT¹¹

Contraindications

Certain conditions require caution or may prevent the use of radial and focused shock wave therapy: 

• A malignant tumor in the treatment area or bone infection (osteomyelitis) are conditions where focused shock wave therapy should not be used for a golfer’s elbow⁷
• Special precautions should be taken where a high energy supply might influence the brain tissue, the structures of the central nervous system or close to vertebral bones, skull or ribs 
• It should not be used if the treatment area includes lung tissue, a malignant tumour, or a pacemaker/defibrillator. Additionally, it is not recommended for individuals with significant blood clotting disorders or if a fetus is present in the treatment area during pregnancy⁷

Limitations of ESWT

ESWT may not be effective in severe or advanced cases of Golfer's Elbow, where the damage is extensive and surgical intervention may be required for optimal results.

Combining ESWT with therapies in treating tendon injuries like golfer’s elbow

Recent research findings suggest that combining ESWT with other treatments like physiotherapy is more effective in treating tendon injuries rather than relying on a single approach. This helps reduce pain and increase function and satisfaction among the people with golfer’s elbow.¹²

Summary

Golfers’ elbow also called medial epicondylitis causes pain behind the medial epicondyle and is caused by the overuse of the forearm muscles, most affecting athletes as well as people in heavy manual labour jobs. Extracorporeal shockwave therapy (ESWT) is a noninvasive method for the treatment of golfer’s elbow, by applying acoustic waves to improve pain and healing of tendons. When used with other forms of treatment such as physiotherapy, one is likely to derive improved pain relief, better functioning, and enhanced recovery rates. ESWT has been considered safe with some minor side effects including redness and bruising of the affected area, and still holds the potential for use as an effective treatment of tendon injuries however severe cases may call for surgery.  With proper assessment, treatment protocols, and post-care, it provides a comprehensive solution for people with golfer’s elbow seeking relief and improved quality of life.