Tennis Elbow and Golfer's Elbow
Ross Hauser, M.D.

The anatomical structures involved in tennis elbow (lateral epicondylitis) and golfer's elbow (medial epicondylitis) are structures located very close to the skin. Thus, being so close to the skin, traditional treatments such as physical therapy, heat, ultrasound, and massage should very quickly resolve the problems by greatly increasing the metabolic rate in the muscle attachments at these sites. However, because these conditions do not recover quickly, this tells us that the muscles are not the problem, but rather, the underlying ligaments.

The annular ligament:

The mighty annular ligament wraps around the radial head and attaches to the ulna, which stabilizes the radius bone when an athlete does any twisting or rotating movement of the elbow. Any kind of throwing motion, whether in javelin, baseball (especially the curve ball), or bowling, puts tremendous force on this ligament. The team physician or athletic trainer rarely examines this ligament, so its injury is never diagnosed. The annular ligament is responsible for the majority of lateral elbow pain that continues for more than a couple of months. In our experience, nearly every patient that comes to our office with this condition has been told they have tennis elbow.
 

The annular ligament is located approximately three-quarters of an inch away from the lateral epicondyle (the "tennis elbow" spot). Its job is to attach the radius bone to the ulnar bone. It is this ligament that enables the hand to rotate, as in turning a key or a screwdriver. It allows a bowler to crank out those big hooks, or the tennis player to hit a big forehand topspin smash. Because of the tremendous demands placed on the fingers and hands to perform repetitive tasks during everyday living (typing) and during athletic events, the annular ligaments becomes lax and a source of chronic elbow pain. The annular ligament also has a distinct referral pain pattern. It refers pain to the thumb, index, and middle fingers. This is the same pain pattern exhibited in Carpal Tunnel Syndrome.
 

Unfortunately, many people with elbow and hand pain have been misdiagnosed with Carpal Tunnel Syndrome. Carpal Tunnel Syndrome refers to the entrapment of the median nerve as it travels through the wrist into the hand. The nerve supplies sensation to the skin over the thumb, index, and middle fingers. A typical Carpal Tunnel Syndrome patient will experience pain and numbness in this distribution in the hand. Because most physicians do not know the referral pain patterns of ligaments, they do not realize that cervical vertebrae ligaments, C4 and C5, and the annular ligament can refer pain to the thumb, index, and middle fingers. Ligament laxity anywhere in the body can cause numbness and pain. Most orthopedic surgeons and athletic trainers do not know that numbness can be a sign of ligament weakness or injury. Cervical and annular Ligament laxity should always be evaluated prior to making the diagnosis of Carpal Tunnel Syndrome. Surgery for Carpal Tunnel Syndrome should not be done until a physician who understands the referral patterns of ligaments and is experienced in Prolotherapy performs an evaluation. The most common reason for pain in the elbow, referring to the hand, is weakness in the annular ligament, not from Carpal Tunnel Syndrome. Several sessions of Prolotherapy will easily strengthen the annular ligament and relieve chronic elbow pain.
 

The Ulnar Collateral Ligament:

The ulnar collateral ligament is the reason for most chronic medial elbow pains. This ligament supports the inside of the elbow. It is responsible for holding the ulnar bone to the distal end of the humerus. This enables the arm to flex, pivoting at the elbow. An athlete's complaint of pain on the inside of the elbow will cause the orthopedist to examine the lateral epicondyle's "sister," the medial epicondyle. The orthopedist will quickly diagnose medial epicondylitis and recommend NSAIDS, or something even worse, the cortisone shot.

The ulnar collateral ligament (UCL) is also important because it refers pain down the arm into the ring and little finger. This same pain and numbness distribution is seen when the ulnar nerve is aggravated. The ulnar nerve lies behind the elbow and is the reason why hitting your funny bone causes pain. Because most physicians are not familiar with the referral pattern of ligaments, elbow pain and/or numbness into the little finger and ring finger is often diagnosed as an ulnar nerve problem, called Cubital Tunnel Syndrome. A more common reason for this condition is ligament laxity in the sixth and seventh cervical vertebrae or in the ulnar collateral ligament, not a pinched nerve. The point to remember here is that if an athlete is given a diagnosis with the word "syndrome," the athlete should turn the other direction and run to the closest Prolotherapy doctor. If the athlete is not significantly better after a month of physiotherapy, it is time to check out of that mode of treatment and check into Prolotherapy.
 

A common mode of treatment for ulnar nerve problems is surgery. The orthopedist removes the ulnar nerve from its normal home in the bottom of the elbow and moves it to the side. Surgery should normally be performed only after all conservative options, including Prolotherapy, have been attempted.
 

Medial and Lateral Epicondylitis

If medial epicondylitis (golfer's elbow) or lateral epicondylitis (tennis elbow) is causing elbow pain, the muscles that attach to these areas are attempting to repair themselves, causing inflammation. The treatment should not be to "anti-inflame," as is the case with cortisone or with anti-inflammatory medications such as ibuprofen. The correct treatment is to strengthen the muscle attachments, which are inflamed due to the body's attempt to strengthen the area. The muscles that extend the wrist attach at the lateral epicondyle, and the muscles that flex the wrist attach at the medial epicondyle. Prolotherapy to strengthen these muscle attachments is very effective in eliminating elbow pain in these conditions.