Pain on the medial side (inside) of the elbow often plagues the overhead athlete. If this pain persists it is usually an indication of either:
- Medial epicondylitis (golfer’s elbow)
- Ulnar collateral ligament (UCL) sprain
- A combination of both of the above
What’s medial epicondylitis?
Medial epicondylitis, commonly referred to as “golfer’s elbow”, involves injury and irritation to a complex of tendons that converge to become the common wrist flexor tendon. This common wrist flexor tendon is mainly responsible for flexing the wrist and fingers, and attaches onto a bone at the inside of the elbow called the medial epicondyle. With injury, movements that generate force through the common wrist flexor tendon produce pain at the medial epicondyle. Most commonly, these movements involve stretching the common flexor tendon by extending the wrist/fingers or contracting the tendon by actively flexing the wrist/fingers. For tennis players, this will likely mean pain with serving and forehands as both these strokes involve aggressive wrist flexion and extension actions.
Just a quick note – the suffix “itis” in “epicondylitis” refers to inflammation and assumes that there is an inflammatory process associated with tendon injury as opposed to a degenerative process. Controversy in the research on this topic has spawned the term “epicondylosis”. So if you’ve ever come across both “epicondylitis” and “epicondylosis” with confusion it’s totally understandable. For the purposes of this post and for simplicity’s sake, we will stick with using “epicondylitis”.
What’s an ulnar collateral ligament (UCL) sprain?
The ulnar collateral ligament (or UCL for short) is a ligament that is responsible for providing support to the inside of the elbow. Similar to the common wrist flexor tendon, the UCL attaches to the medial epicondyle of the elbow and will thus produce pain here when injured. As with any sprain, a UCL sprain will cause pain when force is applied through the ligament. A force termed “valgus stress” puts the most stress on the UCL and will typically produce pain at the medial epicondyle when the UCL is sprained. A great example of valgus stress can be seen in the late cocking/acceleration phases of a baseball pitch or tennis serve (seen in the image below). It is during these actions that pain from a UCL sprain will be most pronounced in the overhead athlete.
How do you tell the difference between medial epicondylitis and a UCL sprain?
Although the location of pain in both conditions will be similar, a UCL sprain will typically be unaffected by wrist and finger movements as it has no direct attachment points there. Instead, a UCL sprain will be affected when valgus stress is applied through the elbow, manifesting in pain, and decreased accuracy and speed during a baseball pitch or tennis serve. Conversely, medial epicondylitis will be most affected by wrist and finger movements but not valgus stress. It is also possible that a UCL sprain and medial epicondylitis can simultaneously co-exist. In this case, wrist movements, finger movements, and elbow valgus will all produce symptoms at the medial epicondyle.
Treatment
Treatment of both medial epicondylitis and UCL sprain will typically involve soft tissue work and specific rehabilitation drills in order to guide tissue healing and regain tissue resilience. Once this has been achieved, rehabilitation will transition into performance optimization. This will involve specific conditioning drills designed to mimic the demands of your sport. In the end, the goal is to increase the resilience of your tissues to a degree that exceeds that of your sport, enhancing your performance and preventing future injury. It is also important to consider the surrounding joints such as the shoulder, wrist, and even the hips and spine. Because of the complex inter-connectivity of the human body, limitations in one joint may contribute to overloading and subsequent injury elsewhere. Thus assessment and treatment of areas other than the area in question may be required for effective intervention and long-term resolution of injury. If you’re a tennis player, it may be important to have your stroke technique analyzed to identify areas that may be contributing to injury.