Golfer's Elbow Release Info Evidence Consent
Reviewed by Dr Kieran Hirpara, Specialist Orthopaedic Surgeon Last reviewed
Why this operation has been suggested
Dr Kieran Hirpara, an upper-limb surgeon at Mater Private Hospital Rockhampton, starts with the least invasive options that suit your condition. Patients are generally referred to our clinic by their GP; if a physiotherapist has suggested you see us, you will still need a referral from your GP in order to be eligible for the Medicare rebate. At your appointment we take a history, examine your elbow, and arrange imaging if it is needed to confirm the diagnosis.
Golfer's elbow is wear and irritation where the tendons that bend your wrist and grip attach to the bone on the inside of your elbow. It often comes on slowly, and the pain can persist even when you rest. We usually begin with non-operative care such as activity change, physiotherapy or hand therapy, and splinting. Surgery is considered when that has not given enough improvement over the long term.
The operation releases the damaged tendon attachment from the bone so the sore area is no longer pulled with each grip or lift. It is offered to people whose pain has not settled with these other treatments. Most elbows treated this way improve, with success reported in 72% to 94% of cases. The aim is lasting relief of pain and better use of your elbow in daily life and sport.
Before the operation
Before surgery you will need some imaging so the operation can be planned. This may include an X-ray, an ultrasound, or an MRI scan, which uses magnets to show the soft tissues around your elbow. Most people need no other tests. If you have other medical conditions, you may need blood tests or a review with the anaesthetist, the doctor who gives your anaesthetic.
On the day, stop eating seven hours before your operation time. We ask for seven hours rather than six so your surgery can be brought forward if the theatre list runs early. Your surgeon will tell you which of your usual medicines to take and which to pause. Bring a list of everything you take. Arrange for someone to drive you home afterwards, and wear loose, comfortable clothing.
On the day
You arrive at the hospital's surgical admissions unit, where you are checked in and prepared for theatre. You then meet the anaesthetist, the doctor who gives your anaesthetic. This operation is done under general anaesthetic. A regional nerve block is sometimes added for post-operative pain relief; the anaesthetist will discuss this with you on the day. You are then taken into the operating theatre, where the operation is performed.
You wake up in the recovery area, where nurses monitor you while the anaesthetic wears off. Once you are stable, you either go to the ward or go home, depending on the procedure and your recovery. Many people having this operation go home the same day. Before you leave, we will explain how to care for your elbow and when your follow-up appointment will be.
What the operation involves
The operation targets the spot on the inside of your elbow where the sore tendons attach to bone. Your surgeon makes a small cut over that bony point and releases the damaged tendon attachment, so it is no longer pulled with every grip or lift. The unhealthy, gristly tissue in the tendon is cleared away, and the healthy tendon is given room to settle back onto the bone and heal.
Some elbows need a slightly different approach. If the nerve that runs along the inside of your elbow is also irritated, your surgeon may free it from the tunnel of tissue it slides through, or move a small piece of bone that is pressing on it. If the joint itself is stiff or has loose bits of tissue catching inside, the operation can be done through two or three small keyhole cuts instead, using a thin camera to see inside the elbow.
The cut is closed with stitches and covered with a dressing. The whole operation usually takes well under an hour, and most people go home the same day.
After the operation
You wake up in the recovery area, where nurses watch you as the anaesthetic wears off. Your elbow will be covered with a dressing, and your arm may rest in a sling for comfort. You can move around soon after waking, and the nurses will help you with anything you need. Pain relief is planned before you leave, and the team will explain how to manage any soreness at home. Someone should stay with you for the first 24 hours. Your team will tell you whether you go home the same day or stay one night in hospital. We leave the dressing on for about 10 days; please do not take it off before then unless we tell you to. We change or remove it when we see you.
Recovery
For the first few days your elbow will be sore and may be swollen. Rest, keeping your hand raised when you can, and the pain relief we plan for you will ease this. The soreness settles gradually as the healing tissue calms down.
You will start gentle movement early. Your hand therapist, Ruby Doolan at Extend Rehabilitation, will guide your exercises and make any splint you need. The aim of the early stages is getting your elbow bending and straightening fully again. Building your grip and arm strength comes next, and it is a big part of getting back to your usual activities.
At home you can use your arm for light tasks as comfort allows. Avoid heavy lifting until we clear you, because the healing tendon needs time to settle back onto the bone. If a movement causes sharp pain, ease back and let your therapist know.
Recovery varies from person to person. Your timeline may differ, and we will guide you along with your therapist at each review.
What can go wrong
Most patients do well, but problems can occasionally happen. Your surgeon and the team monitor you closely to spot any issue early.
The nerve that runs along the inside of your elbow sits close to the operation site. If it is irritated after surgery, you might notice tingling, pins and needles, or numbness in your little and ring fingers. Tell us at your next review if this happens, or call the clinic sooner if it is severe.
Some elbows become stiff after surgery. You might find it hard to straighten your arm fully, or the elbow may feel tight when you bend it. Gentle exercises with your hand therapist usually help. If the elbow stays stiff, we can discuss other ways to regain movement at a review.
The tendons that bend your wrist and grip attach near the same spot. Weakness with gripping or lifting is uncommon, but if you notice your grip feels different, raise it at your next appointment.
Infection is a risk with any operation. Watch for a deep, throbbing pain that does not ease with simple painkillers, redness spreading out from the wound, or fluid leaking from the dressing. If you see any of these, call the clinic straight away rather than waiting for your review.
A blood clot in a vein near the elbow is rare but needs quick treatment. Sudden swelling and tenderness in the arm, or in a calf, should be checked urgently. Go to the emergency department if this happens.
Rarely, the elbow can come out of joint again, or hard lumps of bone can form inside the joint after an injury. A clicking or grinding feeling, or a sudden loss of movement, should be reported to us.
Some people still feel mild pain at the operation site months later. If your pain is not settling the way we described, bring it up at your review so we can look into it.
The complications table on this page lists typical rates if you want the specifics.
When to call us
Call the clinic straight away if you have a fever, or if the wound becomes more red, swollen, or is leaking fluid. Go to the emergency department if you have sudden severe pain, sudden swelling or tenderness in your arm or calf, or shortness of breath. These can be signs of a blood clot. Go to emergency also if you cannot feel your hand, or you cannot move your arm at all. For tingling or numbness in your little and ring fingers that is mild, call us or raise it at your next review.
Evidence & references
This is the clinical evidence summary written for health professionals. It is technical, and it lists the research this page was built from. You do not need to read it to understand your treatment or to make a decision about it.
Anatomy & Pathophysiology
Bony Anatomy
- The elbow is a trocho-ginglymoid joint consisting of medial and lateral articulations that provide bony stability [3].
- The medial articulation involves the trochlea and the ulna within the greater sigmoid notch, forming the ulnohumeral hinged portion [3].
- The ulnohumeral joint exhibits highly congruent anatomy through almost 180° of articular contact, with the exception of a bare area on the greater sigmoid notch devoid of cartilage [3].
- The coronoid process possesses medial and lateral facets that buttress the trochlea anteriorly [3].
- The sublime tubercle is located just distal and medial to the coronoid and serves as the attachment site for the anterior bundle of the medial ulnar collateral ligament [3].
- The medial epicondyle serves as the attachment site for the origins of the flexor pronator mass and is larger and more posteriorly oriented than the lateral epicondyle [3].
- The lateral articulation involves the capitellum and radial head, forming the radiocapitellar joint [3].
- The radius is held in close approximation to the ulna at the proximal radioulnar joint by the annular ligament [3].
- The area of the ulna that articulates with the margin of the radial head at the proximal radioulnar joint is known as the lesser sigmoid notch [3].
- The radial head is a concave elliptical structure covered with articular cartilage along the radiocapitellar joint and approximately 270° of the articular margin [3].
- The radial head articulates with both the capitellum and the lesser sigmoid notch [3].
- The lateral epicondyle is the origin of the lateral extensor musculature [3].
- The origin of the lateral ulnar collateral ligamentous complex is located just distal to the lateral epicondyle at the geometric center of the radiocapitellar articulation [3].
- The distal humeral articulation is angled 30° from the longitudinal axis [3].
- The anterior humeral line should pass through the center of the axis of rotation [3].
- The axis of rotation is angulated 5° to 7° in the coronal plane relative to the epicondylar axis, with the medial side more distal than the lateral side [3].
- The angulation of the distal humeral articulation accounts for the change from a valgus carrying angle to a more varus position as the elbow is flexed [3].
- There is a high correlation between the size of the radius and capitellum on the left and right sides within the same individual [3].
- The olecranon provides a broad attachment site for the triceps [3].
- The ulna bends approximately 8° medially at 8 cm from the tip of the olecranon [3].
- The articulation to the tip of the coronoid is approximately 30° from the long axis of the ulna in the sagittal plane [3].
Ligaments & Stability
- Elbow stability is determined by primary and secondary stabilizers [1].
- The three primary stabilizers of the elbow are the ulnohumeral articulation, the medial ulnar collateral ligament, and the lateral ulnar collateral ligament complex [1].
- Secondary stabilizers include the radiocapitellar articulation, the common flexor tendon, the common extensor tendon, and the joint capsule [1].
- The medial ulnar collateral ligament is the primary valgus stabilizer of the elbow [4].
- The anterior bundle of the medial ulnar collateral ligament is the most important component for stability [4].
- The posterior bundle of the medial ulnar collateral ligament exhibits the greatest change in length and becomes taut at flexion beyond 120 degrees [4].
- The lateral ulnar collateral ligament acts as a posterolateral stabilizer [4].
- Osborne’s ligament stabilizes the ulnar nerve in the cubital tunnel [4].
- The ligament of Struthers is a variant anatomy arising from the supracondylar process to attach to the medial epicondyle and is a potential site of median nerve compression [4].
- Tensile forces are present at the medial elbow, while compressive forces are present at the lateral elbow [4].
- The joint capsule allows maximum distension at approximately 70 to 80 degrees of flexion [4].
- The anterior capsule attaches at a point approximately 6 mm distal to the tip of the coronoid [4].
- The coronoid tip is an intraarticular structure that is visualized during elbow arthroscopy [4].
Muscles & Tendons
- The brachialis is the strongest elbow flexor and attaches to the coronoid 11 mm distal to the tip [4].
- The biceps brachii inserts at the ulnar margin of the radial tuberosity, with the long head inserting proximally and the short head distally [4].
- The biceps brachii is a powerful supinator of the forearm [4].
- The triceps is the primary elbow extensor and inserts on the olecranon process [4].
- The mobile wad consists of the brachioradialis, extensor carpi radialis longus, and extensor carpi radialis brevis [4].
- The flexor-pronator mass consists of the pronator teres, flexor carpi radialis, palmaris longus, flexor carpi ulnaris, and flexor digitorum superficialis [4].
- The common origin of the extensor muscles is attached to the lateral condylar fragment [6].
- The common origin of the extensor muscles can be separated from the lateral epicondyle with a thin flake of bone or divided just distal to the lateral epicondyle [6].
Biomechanics & Motion
- The normal elbow has a range of motion from 0° to 140° from extension to flexion [1].
- The normal elbow has a range of motion of 75° in pronation and 85° in supination [1].
- A functional arc for the elbow is 100° for flexion and extension [1].
- A functional arc for the elbow is 100° for forearm rotation [1].
Investigations
History and Physical Examination
- The physical examination of the elbow is directed by the history and the location of the patient's pain in the anterior, posterior, medial, or lateral aspect of the elbow [1].
- The normal elbow has a range of motion of 75° and 85° in pronation and supination, respectively [1].
- A functional arc for the elbow is 100° for flexion and extension and forearm rotation [1].
- Elbow stability is determined by primary stabilizers, which include the ulnohumeral articulation, the medial ulnar collateral ligament (MUCL), and the lateral ulnar collateral ligament (LUCL) complex [1].
- Secondary stabilizers of the elbow include the radiocapitellar articulation, the common flexor tendon, the common extensor tendon, and the joint capsule [1].
- The ulnar nerve is of utmost importance in the physical examination due to its anatomic proximity to the elbow [9].
- The posterior bundle of the medial collateral ligament (MCL) forms the floor of the cubital tunnel along the course of the ulnar nerve [9].
- Electromyography and nerve conduction velocity studies should be performed if there is any question about neurologic dysfunction [9].
- An assessment for ulnar nerve subluxation should be performed during the physical examination [9].
- Subluxation of the ulnar nerve is a relative contraindication for an arthroscopic procedure secondary to possible iatrogenic nerve injury [9].
- If the elbow has less than 90° to 100° of flexion, the posterior bundle of the medial collateral ligament (MCL) is contracted and must be released to restore flexion [9].
- Pain during the mid-arc of range of motion is more common with intrinsic disease and may not improve with contracture release alone [9].
Imaging
- Plain radiographs remain the hallmark and the best screening test for elbow evaluation [1].
- Standard radiographic views for the elbow include AP, lateral, and oblique views [9].
- Serial radiography is used as follow-up when heterotopic ossification is present [9].
- Primary bony landmarks identified on radiographs include the ulnohumeral joint, coronoid process, radial head, capitellum, radiocapitellar joint, olecranon tip, coronoid/olecranon fossae, and trochlear ridge [9].
- CT is helpful when assessing for malunion architecture and the location and pattern of osteophytes and/or loose bodies [9].
- Three-dimensional CT is used to check for heterotopic ossification [9].
- CT is not necessary when the stiffness is entirely soft-tissue related [9].
- CT is beneficial if any joint incongruity or abnormal bony anatomy is present [9].
- MRI can be used to evaluate ligaments and tendons, but it is rarely indicated for elbow stiffness [9].
- AP, lateral, oblique, and axillary views of the elbow may reveal posteromedial olecranon osteophytes and/or loose bodies in valgus extension overload syndrome [11].
- CT with two-dimensional reconstruction and three-dimensional surface rendering best visualizes the pathology of valgus extension overload syndrome [11].
- MRI may be most helpful in evaluating associated injuries including partial or complete tears of the medial collateral ligament (MCL) in valgus extension overload syndrome [11].
- Radiographic evaluations are essential when diagnosing an osteochondritis dissecans (OCD) lesion of the elbow [12].
- Important aspects of OCD lesions may be better seen with MRI [12].
- Standard AP and lateral radiographs should be obtained for the evaluation of elbow osteoarthritis [13].
- Radiographs for elbow osteoarthritis typically show osteophyte formation at the coronoid process, coronoid fossa, radial fossa, radial head, olecranon tip, and olecranon fossa [13].
- Joint spaces at the ulnohumeral joint are usually preserved in elbow osteoarthritis [13].
- Joint spaces at the radiocapitellar joint are mildly narrowed in elbow osteoarthritis [13].
- Loose bodies may be evident on radiographs, which typically underestimate the number present [13].
- CT may be useful for surgical planning of elbow osteoarthritis, allowing a detailed assessment of osteophytes and the presence of loose bodies [13].
References
[1] Orthopaedic Knowledge Update 13 Ebook Without Multimedia. Anatomy, Biomechanics, Physical Examination, and Imaging of the Elbow > Summary and Conclusions.
[3] Orthopaedic Knowledge Update 13 Ebook Without Multimedia. Anatomy, Biomechanics, Physical Examination, and Imaging of the Elbow > Anatomy > Bony Anatomy.
[4] Miller S Review Of Orthopaedics. SECTION 16 PATELLAR TRACKING IN TOTAL KNEE ARTHROPLASTY > TABLE 2.3 Shoulder Spaces.
[6] Campbell S Operative Orthopaedics 4 Volume Set. LATERAL APPROACHES.
[9] Aaos Comprehensive Orthopaedic Review 3. Elbow Stiffness* > IV. Evaluation.
[11] Aaos Comprehensive Orthopaedic Review 3. Elbow Injuries in the Athlete* > III. Valgus Extension Overload Syndrome and Posterior Impingement.
[12] Orthopaedic Knowledge Update. Osteochondritis Dissecans of the Knee and Elbow* > Summary.
[13] Aaos Comprehensive Orthopaedic Review 3. Arthritis and Arthroplasty of the Elbow > I. Osteoarthritis.
