The Science of Golfer's Elbow

Medial epicondylalgia (golfer's elbow) is a degenerative tendinopathy affecting the common flexor-pronator tendon origin at the medial epicondyle of the humerus, primarily involving the pronator teres and flexor carpi radialis tendons. Despite the name, fewer than 10% of cases occur in golfers. The condition represents a failed healing response resulting in tendinosis rather than tendinitis, characterized by angiofibroblastic degeneration, disorganized collagen structure, increased mucoid ground substance, and neovascularization. The pathophysiological process begins with repetitive mechanical overload of the wrist flexors and forearm pronators exceeding the tendon's capacity for adaptation and repair. This creates microtears in the tendon structure that accumulate faster than the tissue can heal. The body's attempt to repair this damage results in disorganized collagen deposition, increased vascularity with neurogenic ingrowth, and eventual structural weakening rather than strengthening. Histologically, biopsies show angiofibroblastic hyperplasia with absence of inflammatory cells, confirming this as degenerative tendinosis rather than acute inflammation. The flexor-pronator mass originates from a relatively small area on the medial epicondyle and must generate force during gripping, wrist flexion, and forearm pronation - functions required in countless daily activities. The pronator teres and flexor carpi radialis experience the highest loads during gripping activities combined with forearm rotation, making them particularly vulnerable to overload. The medial epicondyle also serves as an attachment site for the ulnar collateral ligament, meaning any valgus stress at the elbow can indirectly stress the flexor-pronator origin. Neurogenic sensitization develops in chronic cases, with elevated substance P and calcitonin gene-related peptide contributing to pain amplification. This neuroplastic change helps explain why some cases become recalcitrant to standard treatment approaches. The condition frequently coexists with ulnar nerve symptoms due to the nerve's proximity to the medial epicondyle, cubital tunnel syndrome, and cervical radiculopathy, requiring careful differential diagnosis. Risk factors include age 40-60 years (peak incidence), occupations requiring forceful gripping with wrist flexion (construction, cooking, assembly work, manual labor), racquet sports with poor technique, overhead throwing sports, and sudden increases in hand-intensive activities. Biomechanical factors such as reduced grip strength, poor proximal stability, and cervical dysfunction contribute to onset and chronicity.