Golfer’s Elbow / Medial Epicondylitis — বাংলা ক্লিনিক্যাল নোট
Golfer’s elbow বা Medial epicondylitis হলো কনুইয়ের ভেতরের দিকে medial epicondyle-এ common flexor–pronator tendon origin-এর overuse tendinopathy/tendinosis। সাধারণত repetitive gripping, wrist flexion ও forearm pronation-এর কারণে tendon-এ microtrauma ও degeneration হয়। Diagnosis বেশিরভাগ ক্ষেত্রে clinical; imaging লাগে atypical, traumatic, persistent বা nerve/ligament injury সন্দেহ হলে।
1. Definition / সংজ্ঞা
Golfer’s elbow = medial epicondylitis / medial epicondylalgia
কনুইয়ের ভেতরের হাড়ের উঁচু অংশে ব্যথা, যেখানে forearm flexor–pronator muscle group-এর tendon attach করে। ব্যথা হাতের ভেতরের দিক দিয়ে forearm/wrist পর্যন্ত ছড়াতে পারে।
2. Cause / Etiology — কারণগুলো
- Repetitive wrist flexion
বারবার কবজি ভাঁজ করা—যেমন hammering, lifting, typing with poor posture, manual work। - Repeated forearm pronation
হাতের তালু নিচের দিকে ঘোরানো movement বারবার করলে tendon load বাড়ে। - Forceful gripping
heavy tool, racket, dumbbell, golf club, cricket bat শক্ত করে ধরলে common flexor tendon strain হয়। - Sports-related cause
golf, tennis, badminton, cricket bowling/throwing, gym weightlifting—বিশেষ করে technique ভুল হলে। - Occupational cause
carpenter, mechanic, plumber, mason, cook, tailor, computer/keyboard-heavy worker—repetitive hand use। - Poor biomechanics / posture
shoulder–scapular weakness, poor wrist position, sudden training increase, inadequate warm-up। - Age-related tendon degeneration
40–60 বছর বয়সে tendon healing capacity কমে; repetitive load থাকলে chronic tendinosis হয়। - Associated medial elbow pathology
Ulnar neuritis/cubital tunnel syndrome, ulnar collateral ligament injury, flexor–pronator strain একসাথে থাকতে পারে—তাই medial elbow pain সবসময় শুধু golfer’s elbow নয়।
3. Pathophysiology — সহজভাবে রোগের প্রক্রিয়া
এটা শুধু “inflammation” না; chronic case-এ tendon-এর collagen disorganization, micro-tear, angiofibroblastic degeneration/tendinosis বেশি গুরুত্বপূর্ণ। Repetitive load tendon healing-এর চেয়ে বেশি হলে pain–weakness–functional limitation তৈরি হয়।
4. Symptoms / Clinical Features — লক্ষণ
- কনুইয়ের ভেতরের দিকে ব্যথা
medial epicondyle-এর উপর বা সামান্য নিচে point tenderness থাকে। - ব্যথা forearm/wrist পর্যন্ত ছড়াতে পারে
হাতের ভেতরের দিক দিয়ে কবজি পর্যন্ত টান টান ব্যথা হতে পারে। - Grip weakness
বোতল খোলা, heavy bag ধরা, হাত মেলানো, dumbbell ধরা—এসব কাজে ব্যথা/দুর্বলতা। - Resisted wrist flexion-এ pain
রোগী কবজি ভাঁজ করতে চাইলে examiner resistance দিলে medial elbow pain বাড়ে। - Resisted forearm pronation-এ pain
হাতের তালু নিচের দিকে ঘোরানোর against resistance-এ pain reproduce হয়। - Passive wrist extension-এ stretching pain
elbow straight রেখে wrist extend করলে flexor tendon stretch হয়, এতে ব্যথা বাড়তে পারে। - Stiffness বা morning discomfort
chronic case-এ কনুই শক্ত লাগে, কাজ শুরুতে ব্যথা বেশি—গরম হলে কিছুটা কমতে পারে। - Ulnar nerve symptom থাকলে সতর্কতা
ring/little finger ঝিনঝিন, numbness, intrinsic hand weakness থাকলে cubital tunnel/ulnar neuritis evaluate করতে হবে।
5. Clinically Diagnosis — কীভাবে clinically diagnose করবেন
Diagnosis mainly clinical. Key findings:
- Site of tenderness
Medial epicondyle-এর anterior/inferior aspect বা common flexor tendon origin-এ localized tenderness। - Provocation tests
- Resisted wrist flexion → pain
- Resisted forearm pronation → pain
- Passive wrist extension with elbow extended → pain
- Painful grip test → grip pain/weakness
- Rule-out examination
- Ulnar nerve: Tinel sign at cubital tunnel, 4th/5th finger sensation, interossei weakness
- UCL injury: valgus stress/moving valgus stress test, throwing athlete হলে বেশি গুরুত্বপূর্ণ
- Neck/shoulder: cervical radiculopathy বা referred pain exclude
- Lateral epicondyle: tennis elbow exclude
- Joint: ROM, swelling, locking, effusion
Orthobullets summary অনুযায়ী diagnosis clinical, এবং tenderness medial epicondyle-এ থাকে যা resisted forearm pronation ও wrist flexion-এ worsen করে।
6. Investigations — specific কী কী করবেন
A. Routine uncomplicated case
No investigation initially needed যদি classic history + examination থাকে।
B. X-ray elbow AP/Lateral
কখন করবেন:
- trauma history
- severe stiffness
- suspected fracture/avulsion
- osteoarthritis/calcification
- chronic pain not improving
C. Ultrasound / MSK USG
কখন করবেন:
- tendon thickening, hypoechoic degeneration, partial tear দেখতে
- dynamic assessment
- injection guidance
- cost-effective option
D. MRI elbow
কখন করবেন:
- 3–6 মাস conservative treatmentেও improvement না হলে
- tendon tear suspicion
- UCL injury suspicion
- ulnar nerve pathology
- surgery planning
Mayo Clinic investigation listে X-ray ও MRI উল্লেখ আছে, আর modern reviews imaging use করে differential pathology rule out করতে বলে।
E. Nerve conduction study / EMG
কখন করবেন:
- 4th/5th finger numbness
- hand intrinsic weakness
- persistent tingling
- suspected cubital tunnel syndrome / ulnar neuropathy
F. Lab tests — routine নয়
CBC, ESR/CRP, uric acid, RF/anti-CCP only if:
- inflammatory arthritis suspicion
- infection suspicion
- gout/pseudogout suspicion
- systemic symptoms
7. Differential Diagnosis
- Cubital tunnel syndrome / ulnar neuritis
- Ulnar collateral ligament injury
- Flexor–pronator strain/tear
- Medial triceps snapping syndrome
- Cervical radiculopathy C8–T1
- Elbow osteoarthritis
- Olecranon/medial elbow bursitis
- Fracture/avulsion injury
- Inflammatory arthritis
- Gout/pseudogout
8. Complications — বাংলায় বোঝানো
- Chronic pain
চিকিৎসা না করলে pain months–year চলতে পারে। - Grip strength কমে যাওয়া
হাতের কাজ, lifting, writing, typing, sports performance কমে যায়। - Recurrent flare-up
একটু কাজ করলেই বারবার ব্যথা ফিরে আসে। - Tendon degeneration/partial tear
repeated overload চললে tendon আরও দুর্বল হতে পারে। - Ulnar nerve irritation
medial elbow pathology ulnar nerve-এর কাছাকাছি, তাই ঝিনঝিন/numbness হতে পারে। - Work/sport limitation
manual worker বা athlete-এর productivity কমে যায়। - Steroid injection complication
skin depigmentation, subcutaneous fat atrophy, post-injection flare, infection, rare tendon rupture—তাই repeated blind injection avoid করতে হবে। Steroid injection সাধারণত first-line failure-এর পর বিবেচনা করা হয়।
9. Treatment / Management — guideline-based
A. Non-pharmacological management: main treatment
- Relative rest, complete immobilization নয়
pain-provoking কাজ temporarily কমাবেন; হাত একদম নাড়াচাড়া বন্ধ করবেন না। - Ice therapy
acute flare-এ 15–20 মিনিট, দিনে 2–4 বার। - Counterforce brace / elbow strap
medial epicondyle-এর 2–3 cm distal forearm-এ strap দিলে tendon load কমে। - Wrist splint
রাতে বা কাজের সময় wrist neutral রাখতে পারে—especially repetitive wrist flexion হলে। - Physiotherapy
- Wrist flexor stretching
- Pronator stretching
- Eccentric wrist flexor strengthening
- Grip strengthening
- Shoulder–scapular–core conditioning
AAOS বলছে tendon-attached muscle stretch/strengthening healing ও repetitive stress tolerance বাড়াতে সাহায্য করে।
- Eccentric exercise
Chronic medial epicondylosis-এ eccentric wrist flexor exercise standard therapy-এর সাথে outcome improve করতে পারে। - Injection
Steroid injection short-term pain relief দিতে পারে, কিন্তু first-line নয়; activity modification, brace, analgesic ও PT fail করলে specialist setting-এ। - Surgery
6–12 মাস adequate conservative treatment fail, severe disability, tendon tear বা associated ulnar nerve problem থাকলে orthopedic referral।
10. Pharmacological Drugs — Bangladesh prescription-oriented list
Rule: একসাথে একাধিক oral NSAID দেবেন না। CKD, peptic ulcer/GI bleed, anticoagulant use, uncontrolled HTN, IHD/HF, asthma with NSAID sensitivity, pregnancy 3rd trimester—oral NSAID avoid/caution।
1) Generic name: Paracetamol
Therapeutic category: Analgesic, antipyretic
Pharmacological class: Non-opioid analgesic / para-aminophenol derivative
Purpose: mild pain relief; inflammation কমায় না, কিন্তু pain control safe option। MedEx paracetamol/Napa pain, myalgia, sprain, rheumatic pain-এর indication উল্লেখ করে।
Adult dose: 500 mg 6–8 hourly PRN; usual max 3 g/day, selected adults max 4 g/day if no liver risk.
Duration: 3–5 days PRN; chronic daily use avoid.
Bangladesh available brand examples with strength:
Napa 500 mg, Napa Extend 665 mg, Reset 500 mg, Fast 500 mg/1000 mg, Feva 500 mg, M-Pol 500 mg, Ace 500 mg suppository.
Side effects: usually mild; rash/allergy, nausea; overdose → severe hepatotoxicity. MedEx notes rare hematological reactions and pancreatitis/allergic reactions.
Important interactions: alcohol, enzyme inducer drugs such as phenytoin/carbamazepine/phenobarbital/rifampicin can increase liver risk; avoid multiple paracetamol-containing products.
2) Generic name: Diclofenac Sodium topical gel
Therapeutic category: Local analgesic/anti-inflammatory
Pharmacological class: NSAID, phenylacetic acid derivative
Purpose: localized medial elbow pain; oral NSAID contraindicated হলে safer first option। MedEx diclofenac gel external use 2–4 g 3–4 times daily উল্লেখ করে।
Dose: Diclofenac gel 1%: 2–4 g thin layer over painful medial elbow, 3–4 times/day.
Duration: 7–14 days; skin irritation হলে বন্ধ।
Bangladesh available brand examples with strength:
Diclofen Gel 1%, DicloGel 1%, Voligel 1%, Volifen 1%, Voltafen 1%, Voligel Max 2%.
Side effects: local redness, rash, eczema, irritation.
Interactions: systemic absorption কম, তবে large area/long duration হলে oral NSAID/anticoagulant use-এ caution।
3) Generic name: Ibuprofen
Therapeutic category: Analgesic, anti-inflammatory
Pharmacological class: NSAID, propionic acid derivative
Purpose: acute flare-এ pain + inflammation control; short course। MedEx mild–moderate pain/inflammatory pain-এ adult 200–400 mg 3–4 times/day উল্লেখ করে।
Dose: 400 mg after meal, 8 hourly PRN.
Duration: 3–5 days; max 1200 mg/day OTC range; prescription settingে patient risk অনুযায়ী।
Bangladesh available brand examples with strength:
Advel 400 mg, Flamex 400 mg, Profen 400 mg, Reumafen 400 mg, Serviprofen 400 mg, Intaflam 400 mg.
Side effects: dyspepsia, gastritis/ulcer, dizziness, headache, fluid retention, renal function deterioration, BP rise. MedEx common effectsে headache, somnolence, vertigo, fatigue, dizziness, insomnia and GI ulcer উল্লেখ করে।
Interactions: anticoagulant/antiplatelet, aspirin, corticosteroid, other NSAIDs, ACE inhibitor/ARB, diuretic, lithium, methotrexate, cyclosporine/tacrolimus, quinolone, fluconazole/voriconazole—caution/avoid.
4) Generic name: Naproxen Sodium
Therapeutic category: Analgesic, anti-inflammatory
Pharmacological class: NSAID, propionic acid derivative
Purpose: tendonitis/bursitis-type musculoskeletal painে useful; longer duration effect, usually BD dosing। MedEx naproxen tendonitis, bursitis and pain-এর indication উল্লেখ করে।
Dose: 250–500 mg after meal, 12 hourly PRN.
Duration: 5–7 days; high-risk patientে avoid or PPI cover।
Bangladesh available brand examples with strength:
Naprox 500 mg, Naprosyn 500 mg, Naxin 500 mg, Sonap 500 mg, Napryn 500 mg, Napsod 550 mg, Naprox/Naxin gel 10%.
Side effects: dyspepsia, nausea, GI ulcer/bleeding, dizziness, edema, renal impairment, BP rise.
Interactions: anticoagulant/antiplatelet, steroid, SSRI, ACEi/ARB + diuretic, lithium, methotrexate, other NSAIDs—bleeding/renal risk বাড়ে।
5) Generic name: Aceclofenac
Therapeutic category: Analgesic, anti-inflammatory
Pharmacological class: NSAID, phenylacetic acid derivative
Purpose: musculoskeletal pain and inflammation; Bangladesh doctors often short-course use করেন। MedEx dose adult 100 mg twice daily এবং therapeutic class NSAID হিসেবে উল্লেখ করে।
Dose: 100 mg after meal, 12 hourly.
Duration: 5–7 days.
Bangladesh available brand examples with strength:
Flexi 100 mg, Flexi SR 200 mg, Ceclofen 100 mg, Clof 100 mg, Dolonac 100 mg, Paino 100 mg, Fenaaf 100 mg.
Side effects: dyspepsia, abdominal pain, nausea, dizziness, edema, renal impairment; ulcer/bleeding risk।
Interactions: lithium/digoxin level বাড়তে পারে; anticoagulant effect বাড়তে পারে; methotrexate level বাড়তে পারে; diuretic effect কমতে পারে।
6) Generic name: Etoricoxib
Therapeutic category: Analgesic, anti-inflammatory
Pharmacological class: Selective COX-2 inhibitor NSAID
Purpose: gastric intolerance থাকলে non-selective NSAID-এর alternative হিসেবে কখনো ব্যবহার হয়; কিন্তু cardiovascular risk থাকলে caution। MedEx etoricoxib 60/90/120 mg brand availability দেখায় এবং therapeutic class NSAID।
Dose: 60 mg once daily after meal.
Duration: 3–7 days; lowest effective dose, shortest duration.
Bangladesh available brand examples with strength:
Etocox 60/90/120 mg, Eto 60/90/120 mg, Etorica 60/90/120 mg, Etonil 60/90/120 mg, Etofax 60/90/120 mg.
Side effects: dyspepsia, edema, hypertension, palpitation, renal impairment; MI/stroke risk high-risk patientে concern।
Interactions: warfarin/anticoagulant, ACEi/ARB/diuretic, lithium, methotrexate, other NSAIDs।
7) Generic name: Esomeprazole
Therapeutic category: Gastroprotection / anti-ulcer
Pharmacological class: Proton pump inhibitor
Purpose: oral NSAID দিলে high GI-risk patientে gastritis/ulcer risk কমাতে। MedEx esomeprazole GERD/erosive esophagitis indication ও brands দেখায়।
Dose: 20 mg once daily before breakfast.
Duration: NSAID course চলাকালীন 5–10 days; ulcer history থাকলে individualized।
Bangladesh available brand examples with strength:
Esotid 20/40 mg, EZ-20 20 mg, Exor 40 mg, Gaspro 40 mg, Exium MUPS 20 mg.
Side effects: headache, abdominal discomfort, nausea, diarrhea/constipation; long-term useে B12/Mg deficiency, fracture, C. difficile risk।
Interactions: clopidogrel effect reduce হতে পারে; warfarin/diazepam/phenytoin monitoring; long-term with methotrexate caution।
8) Generic name: Naproxen Sodium + Esomeprazole Magnesium
Therapeutic category: NSAID + gastroprotective combination
Pharmacological class: NSAID + PPI fixed-dose combination
Purpose: NSAID দরকার কিন্তু gastric risk আছে—তখন একসাথে pain control + ulcer risk reduction। MedEx combination brands 375/500 mg naproxen + 20 mg esomeprazole দেখায়।
Dose: 500 mg + 20 mg once or twice daily after/before meal depending product instruction and patient risk.
Duration: 5–7 days.
Bangladesh available brand examples with strength:
Naprox Plus 500+20 mg, Naxin Plus 500+20 mg, Naprosyn Plus 500+20 mg, Napsec 500+20 mg, Naspro Plus 500+20 mg, Naprozol 500+20 mg.
Side effects/interactions: naproxen-এর NSAID risks + esomeprazole-এর PPI risks; anticoagulant/antiplatelet/ACEi/ARB/diuretic/methotrexate caution।
9) Generic name: Triamcinolone Acetonide injection
Therapeutic category: Local anti-inflammatory injection
Pharmacological class: Synthetic glucocorticoid corticosteroid
Purpose: severe pain বা chronic case যেখানে rest, brace, analgesic, physiotherapy fail করেছে—short-term pain relief। MedEx triamcinolone soft tissue/intra-articular useে epicondylitis indication উল্লেখ করে।
Usual specialist dose: 10–20 mg local peritendinous injection; never intratendinous; ultrasound-guided preferable.
Duration/frequency: single injection; repeat হলে usually 6–12 weeks gap, total repeated injections সীমিত।
Bangladesh available brand examples with strength:
Alfacort 40 mg/ml, Cenolon 40 mg/ml, Cynocort 40 mg/ml, Emicort 40 mg/ml.
Side effects: post-injection flare, pain, infection, skin depigmentation, fat atrophy, hyperglycemia, tendon rupture rare।
Interactions/caution: diabetes, anticoagulant use, local infection, immunosuppression; repeated injection tendon weakening করতে পারে।
10) Generic name: Methylprednisolone Acetate injection
Therapeutic category: Local anti-inflammatory injection
Pharmacological class: Glucocorticoid corticosteroid
Purpose: triamcinolone alternative for local steroid injection when specialist decides। MedEx methylprednisolone acetate 40 mg/ml and 80 mg/2 ml injection brands দেখায়।
Usual specialist dose: 20–40 mg local peritendinous injection, often local anaesthetic with/without; avoid tendon substance।
Duration/frequency: single injection; repeat only if clinically justified.
Bangladesh available brand examples with strength:
Depo-Medrol 40 mg/ml, Depo-Medrol 80 mg/2 ml, Depo-pred 40 mg/ml, Depomed 40 mg/ml or 80 mg/2 ml, Medrol 40 mg/ml or 80 mg/2 ml, Methsolon 40 mg/ml.
Side effects/interactions: same corticosteroid injection risks; diabetes hyperglycemia, infection risk, anticoagulant bleeding risk, repeated injection tendon weakening।
11. Bangladesh doctors commonly prescribe — practical list
For uncomplicated adult Golfer’s elbow, Bangladesh practice commonly follows these patterns:
- Mild pain:
Paracetamol 500 mg PRN + Diclofenac gel 1% local + rest/brace/PT.
কেন: pain কমায়, systemic NSAID risk কম। - Moderate acute pain:
One oral NSAID only—Ibuprofen 400 mg TDS or Naproxen 500 mg BD or Aceclofenac 100 mg BD for short course.
কেন: pain + inflammatory mediator reduction; function improve করতে short-term support। - Gastric risk থাকলে:
NSAID-এর সাথে Esomeprazole 20 mg OD অথবা Naproxen+Esomeprazole fixed combination.
কেন: NSAID-induced dyspepsia/ulcer risk কমাতে। - High GI/renal/CV risk:
Prefer topical diclofenac + paracetamol + physiotherapy; oral NSAID avoid.
কেন: systemic adverse effects কম। - Persistent pain despite 6–12 weeks treatment:
Orthopedic/PM&R referral; USG-guided steroid injection/PRP/ESWT consider.
কেন: chronic tendinosis-এ targeted therapy দরকার হতে পারে। - Numbness/tingling/weakness:
EMG/NCS ± MRI; ulnar neuritis/cubital tunnel rule out.
কেন: শুধু golfer’s elbow treat করলে nerve disease miss হতে পারে।
12. Prevention — কীভাবে প্রতিরোধ করবেন
- কাজ/খেলার আগে 5–10 মিনিট warm-up।
- Wrist flexor–pronator stretching daily।
- Eccentric strengthening সপ্তাহে 3–5 দিন।
- Heavy gripping কমানো; tool handle বড়/soft grip ব্যবহার।
- Computer work করলে wrist neutral posture।
- Sudden weight/training increase না করা—10% rule।
- Golf/racket/cricket technique correct করা।
- Pain শুরু হলে “play through pain” না করা; temporary load reduction।
- Recurrence prevent করতে pain চলে গেলেও home exercise চালিয়ে যাওয়া—StatPearls recurrence prevention-এ eccentric strengthening/stretching continuation উল্লেখ করেছে।
Overview / Summary
Golfer’s elbow হলো medial elbow-এর common flexor–pronator tendon origin-এর overuse tendinopathy। Diagnosis mostly clinical: medial epicondyle tenderness + resisted wrist flexion/pronation pain। Treatment-এর মূল হলো activity modification, brace, stretching, eccentric strengthening; medicines শুধু pain control-এর supportive part। Steroid injection first-line নয়—failed conservative therapy বা severe persistent pain-এ specialist-guided।
Actionable Plan / Steps
- First 1–2 weeks: aggravating work কমানো, ice, diclofenac gel, paracetamol PRN, elbow strap।
- Pain moderate হলে: contraindication না থাকলে one oral NSAID 3–7 days + PPI if GI risk।
- Week 2 onward: physiotherapy—stretching → eccentric flexor/pronator strengthening।
- 6–12 weeksেও pain থাকলে: USG/MRI consider, ulnar nerve signs থাকলে EMG/NCS।
- 3–6 months refractory: orthopedic/PM&R referral; USG-guided injection/PRP/ESWT/surgery assessment।
Reference List
- Textbook: Davidson’s Principles and Practice of Medicine, 24th ed. Musculoskeletal pain and regional soft-tissue disorders section.
- Textbook: Harrison’s Principles of Internal Medicine, 21st ed. Rheumatology & musculoskeletal symptoms section.
- Specialty textbook: Morrey’s The Elbow and Its Disorders, 5th ed. Chapter: Medial epicondylitis/tendinosis.
- Guideline/clinical resource: AAOS OrthoInfo. Therapeutic Exercise Program for Epicondylitis.
- NIH/NCBI: StatPearls. Medial Epicondylitis / Medial Epicondyle Injection.
- Review with DOI: Konarski W, et al. Current concepts of natural course and management of medial epicondylitis: a clinical overview. Orthopedic Reviews. 2023;15:84275. doi: 10.52965/001c.84275.
- Review with DOI: Prabhakar G, Kanawade V, Ghali AN, Dutta AK, Brady CI, Morrey BF. Medial Elbow Pain Syndrome: Current Treatment Strategies. Orthopedics. 2023;46(2):e81–e88. doi: 10.3928/01477447-20220719-06.
- Clinical study: Tyler TF, et al. Clinical outcomes of the addition of eccentrics for rehabilitation of previously failed treatments of golfer’s elbow. Int J Sports Phys Ther. 2014;9(3):365–370.
- Drug reference Bangladesh: MedEx Bangladesh drug monographs and brand lists for paracetamol, diclofenac, ibuprofen, naproxen, aceclofenac, etoricoxib, esomeprazole, triamcinolone, methylprednisolone acetate.
Md.Rafiqul Islam Lipu,Date:-13-06-2026 Saturday,Time:-03-28-12 Pm