My Management of Golfers Elbow
My thoughts and experience on treating Golfers Elbow including two case studies
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The last few years I’ve started treating Golfers (and Tennis) Elbow a little different and have been getting good outcomes. My patients and myself find the process quite simple and clear and we’ve been surprised with the results. I’m happy to share this process with you.
The usual disclaimer: This is not gold-standard research, this is a blog post, from one guy sharing his clinical experience with the world, so references are minimal. For patients, this process is not a recipe for your elbow pain, see a registered and regulated health professional for a comprehensive assessment and management plan tailored to you.
Select here a very similar blog-article on on Tennis Elbow
Terminology
In the research you will find Golfers Elbow as “Medial Epicondylitis”
Medial Epicondylitis refers to the inflammation of the round bit of bone on the inside of the upper arm bone (humerus — medial epicondyle).
Medial = towards anatomical midline (inside bit) , epi = outside layer, condylus = round bit of bone, -itis = inflammation. Therefore Medial Epicondylitis is inflammation of the round bit of bone on the inside of your elbow…and the structures that attaches to it.
Medial Epicondylitis aka “Golfers Elbow” is the lesser of 2 common evils in the elbow, the other being the infamous Tennis Elbow. Golfers elbow has been reported to have a prevalence 5x less than Tennis Elbow and mostly in the dominant arm (Shiri, Viikari-Juntura, Varonen, & Heliövaara, 2006). I think we are also less likely to see Golfers Elbow due to it being much more of a ‘self-limiting’ (gets better with time once the patient stops doing whatever hurts it) injury than Tennis Elbow which tends to persist. Like tennis elbow it has a high incidence with occupational mechanisms of injury as well as sports and exercise mechanisms where it is reported amongst Golfers, throwing athletes, baseball players and tennis players (Descatha, Leclerc, Chastang, & Roquelaure, 2003).
The research reports it appears in the 40–60 year old cohort equally amongst men and women (Shiri et al., 2006), however I also see it most often in the 35–50 year old cohort with a handful of younger adults (20–35 year olds) who have a high medial elbow load such as tennis players and body builders. The Shiri 2006 prevalence study only looked at a population >35years of age so may have missed a younger cohort with the condition.
Although both Tennis Elbow and Golfers Elbow both involve a bone-tendon attachment site, the cause of injury is much different, and Golfers Elbow takes a fair bit of work by the patient to develop.
What is it?
Much like “tennis elbow”, this condition has been labelled after a sport where the condition was quite common. It was reported that Golfers Elbow would occur due to the valgus loads on the medial elbow during the late swing phase (Batt, 1993).
However, unless Clinicians are working in a Golf-crazy town or on the Golf Pro Tour, we will more often see Golfers Elbow in other populations who aren’t golfers.
For me, sports-related Golfers elbow is more common from tennis players from serve and forehand at the cocking stage, in throwers (baseball etc) at the cocking phase and in gym-goers who have a high anterior forearm load (eg: climbers, pull-ups/hangs and rack position during clean and jerk). Otherwise, I’m more likely to see it from occupational causes (or a mix of sports and occupation).
Golfers Elbow involves the origin of the common flexor tendon (CFT) of the wrist flexors: Pronator Teres, Flexor Carpi Radialis, Flexor Digitorum Superficialis, Palmaris Longus, Flexor Carpi Ulnaris (PT, FCR, FDS, PL, FCU). Of these the FCR and PT contribute the most (Ollivierre, Nirschl, & Pettrone, 1995).
The CFT originates above the elbow joint at the medial epicondyle (MEC) of the humerus, crossing the elbow joint, the wrist flexors travel down the forearm and cross the wrist joint, attaching at the wrist/hand. This is important as this makes the wrist flexors not just prime movers (wrist flexion) but also stabilisers at two joints (wrist and elbow). The wrist flexors keep the wrist still so that it can transfer power whilst the wrist is trying to limit wrist extension, such as a racquet hitting a ball in tennis trying to push the wrist back, or a gym weight held in a palm up position which tries to push the wrist down into extension.
The CFT also helps the medial (inside) elbow ligaments (UCL ligament complex) and contributes to stabilisation of the inside of your elbow when a force is pushing your elbow into “valgus”.
The beautiful thing about tendons is: If a tendon is painful, they are (usually) very good at telling you because they produce a very localised pain. In other words, if there is pain that travels away from the medial (inside) elbow down towards the hand or up the upper arm then it’s likely that either it’s not Golfers Elbow or it is Golfers Elbow but there is more going on.
Golfers Elbow will involve the CFT usually 5–10mm distal and anterior to the MEC (Ciccotti & Ramani, 2003).
At this point, shout-out to my colleague Pat Kirk who spotted me drawing on my arm and doing an awkward “elbow selfie” for this photo and accidently said “need a hand?”. Brilliant accidental pun. Well done Pat.
This area (medial elbow) also has a few other structures that might need consideration/ruling out.
Differential Diagnosis
Little League Elbow and UCL Complex
This should only be a consideration in kids/adolescents with a high load of throwing/hitting. Basically it’s a apophyseal issue at the medial epicondyle of the humerus. I only mention it as there may be some crossover with young elite tennis players where they have a high and powerful hitting load between ages 14–19 where there may still be some growth plate involvement.
Otherwise, the UCL complex at the medial elbow should not be too stressed in the adults who tend to get Golfers Elbow (30+ year olds) unless there has been a traumatic mechanism of injury.
Traumatic Medial Elbow
For medial elbow pain as a result of direct blows, one would want to rule out bony injuries such as fractures and avulsion fractures, however the majority of Golfers Elbow cases occur with a gradual non-acute/non-traumatic onset.
The Ulnar Nerve
The Ulnar nerve (the funny bone nerve) travels through this area and is often involved with Golfers Elbow (Amin, Kumar, & Schickendantz, 2015). If there is any shooting pain or neural symptoms travelling down towards the ulnar side of the hand (pinky finger side) then the Ulnar side could be involved.
Cubital Tunnel Syndrome is an irritation of the Ulnar nerve as it travels through the cubital tunnel, it could present like an “ulna-sided carpal tunnel syndrome” with hand/wrist symptoms in the ulnar half of the hand/wrist (pinky finger half), this needs to be ruled out.
Likewise if there is a shooting pain that goes from the medial (inside) elbow up the arm, it could be the ulnar nerve… but it could also be:
The Triceps Tendon
The triceps tendon attaches to the nearby olecranon of the ulna, however some fascial connections or the triceps itself may stir up/compress the ulnar nerve with active or resisted elbow extension activities or prolonged elbow flexion (eg: sleeping with elbow fully bent). This will elicit pain in a different area to golfers elbow.
Finally, if there is a broad referral of pain near the medial elbow but it appears to be more vague than the wrist flexor tendon at the medial elbow, the clinician needs to rule out:
The Cervical Spine — C6-C7 (+/- 1 level)
C6/C7 Cervical Spine radiculopathy and/or radicular pain will need to be ruled out with a cervical and thoracic spine examination looking for reproduction of symptoms down the ulnar side of the arm, or even just localised pain at the cervicothoracic (neck-upper back) junction which may sensitise the peripheral nervous system, and in particular the ulnar nerve in the arm.
Finishing your assessment
Once the clinician has ruled out all other causes of medial elbow pain, they might want to also assess the rest of the “anterior chain” of the upper arm, such as the biceps and pecs to see if there are any other nearby kinetic chain drivers for overload of the wrist flexors.
Bony-Attachment vs Mid-Portion Tendon Management
We have a pretty good research base on tendon management following the last 15 or so years of research from Purdham, Cook and Rio (J. Cook & Purdam, 2009; Rio et al., 2015) as well as others, however looking primarily at lower limb tendons such as achilles and patella tendons. We also have a pretty good research base on lateral elbow tendinopathy management from the likes of Vicenzino and Bisset (Bisset & Vicenzino, 2015; Vicenzino, 2003). The basis of tendinopathy management is to settle down the tendon and gradually increase the capacity of the tendon to sustain load. The ‘bucket and water’ metaphor is often used, water is load, bucket is the tendon capacity. “Reduce the water whilst increase the bucket size and then add more water” is the goal.
For my management of Golfers Elbow I treat it as a mix of Tennis Elbow, where emphasis is heavily on activity modification and calming it down, and lower limb tendinopathies which require load to settle down.
For golfers elbow with a painful mid-portion tendon (as opposed to attachment site), due to the location crossing the medial elbow joint, I think they are stirred up by their role as medial elbow stabilisers when also coupled as resister of wrist extension. They will often require more load to settle following the tendinopathy rehab pathway of isometric (hold) load -> heavy slow isotonics (concentric and eccentric) → power (load with speed).
Whereas I find that bony-attachment tendinopathies, aka Enthesopathies (enthesis is the attachment site of tendons, -opathy means ‘problem at’), usually require more of a rest and activity modification focus than targeted load through the tendon. Enthesopathies also require the clinician to dial back all ‘internal compression loads’ (J. L. Cook & Purdam, 2012). Internal compression is where the tendon gets compressed against bony or other structures due to the position the body is in., Proximal Hamstring Tendinopathy and Tennis Elbow, all of which wholly or partly involve a compression load on the tendon at the attachment site.
For Golfers Elbow, a compressive load would occur either with the elbow being pushed into “cubital valgus” and/or elbow extension, which compresses the tendon into the medial elbow structures, and/or the wrist being pushed into wrist extension, which would tension the wrist flexor tendon into the medial elbow structures. Therefore, it’s important to identify whether the tendon is a bony-attachment issue or a mid-portion issue because the clinician will not want to prescribe wrist flexor stretches as these will cause further ‘internal compression’ loads on the tendon. As is the case with Insertional Achilles Tendinopathy and calf stretches, Lateral Hip Pain/Gluteal Tendinopathy and glute stretches, Proximal Hamstring Tendinopathy and hamstring stretches and, I suspect, Tennis Elbow and wrist extensor stretches.
Specific Assessment
Once all other causes of medial elbow pain have been ruled out, and measures of wrist/elbow ROM and valgus testing have been completed without any issues, we need to measure some Golfers Elbow specific assessment items.
The Wrist Flexion Force Production (WF-FP) Test
First of all, the clinician should check the unaffected side. As with Tennis Elbow testing and other tendon testing, I’m looking to assess their wrist flexion force production (WF-FP).
For Golfers Elbow I use a handheld dynamometer (HHD) and have the patient lying supine with their elbow bent, to help stabilise the upper limb and reduce any other contributors to force production.
I perform a ‘make test’ which is where you stabilise the proximal segment (the forearm) and ask the patient to flex their wrist into the HHD as hard as they can (average of 3 trials). This is their ‘unaffected pain free WF-FP’ number. I then assess the WF-FP of their affected arm however I ask them to gradually build up the force until the pain starts and don’t push any further (average of 3 trials), this is their ‘affected pain-free WF-FP’ number.
I then divide the affected WF-FP/unaffected WF-FP (eg: 25kg/35kg) and get a % (eg: 71% WF-FP).
A ‘break test’ is when you ask the patient to resist the HDD as it pushes into the palm and tries to push the wrist flexors to failure and get the wrist into extension, it should only be conducted if the affected WF-FP is pain-free, which is usually later in the rehab once it’s settled down.
Other assessment items
Other assessment items one can keep track of other than %WF-FP is reduction of symptoms over the week with specific items. Example: Tennis Serve Pain, Bicep Curl Pain. These can be monitored with a Patient-Specific Functional Scale questionnaire/outcome measure formally, or less formally by just asking the patient each time you see them and keeping track of it. https://www.physio-pedia.com/Patient_Specific_Functional_Scale
A painful vs pain-free elbow valgus stress test (at 30deg elbow flexion) is an important item to note.
The location of pain can also be a good indicator for progress, if the mid-portion tendon pain migrates towards the bony attachment (enthesis), this could be a good sign however management will shift gears a little (see the second case study below)
Grip strength testing is rarely impacted with Golfers Elbow, perhaps if the elbow is very irritable there may be use for assessing it, otherwise Grip strength testing will mostly affect the lateral elbow.
Diagnostic Imaging
Only if there is something weird going on would any clinician consider getting any diagnostic imaging involved. It’s also not uncommon (~25%) to find calcification on XR imaging at the UCL or CFT (Ciccotti & Ramani, 2003). Ultrasound has been found to be >90% specific and sensitive in finding hypoechoic changes to the CFT (Park, Lee, & Lee, 2008) however as with all ultrasounds its specificity/sensitivity depends on the sonographer.
MRI would be better suited to help look at the medial elbow as you can differentiate between structures better and see acute vs chronic changes. However, one MRI study found that 20% people without elbow pain (asymptomatic) exhibited thickened common flexor tendons with increased signals, where as 15% of people with diagnosed medial epicondylitis had no changes on MRI (Kijowski & De Smet, 2005).
So , as with all diagnostic imaging, clinicians need to treat the patient and not their scan. Imaging findings must be considered in context with a thorough assessment. Physiotherapists and Specialists are well placed for this if imaging is required. We must avoid turning patients into VOMITs (Victims of medical imaging technology).
Management
Activity Modification
As with Tennis Elbow, activity modification is crucial. The clinician must hunt for the mechanism of injury. Tendon injuries like Golfers Elbow don’t come out of nowhere, there should be an overload mechanism somewhere and the Clinician has to hunt it down otherwise run the risk of the patient continuing to overload their elbow. For the upcoming case studies there were clear mechanisms of injury.
I think advice/education is only well prescribed if it is also emailed to the patient following their appointment. There’s that saying going around “patients hear 1/3 of what you’re telling them and they only understand 1/3 of that” or something similar so it’s very important that I have the time in my appointment to not only simply explain the condition so they can understand it (and repeat it back to you) but also use that same narrative/language in an email following the session for the patient. It is also very handy for them in the future if the condition represents itself, patients find this level of care very valuable, yet disturbingly rare, in healthcare.
Optimal Tendon Loading
As with most Tendinopathy conditions, tendon load will be important in calming down the pain.
For those who haven’t read my take on “Tendinopathy” and why load is thought to help, go to the Tennis Elbow Blog and scroll down until you see the below picture and have a read.
But very basically, tendon gets overloaded, tendon gets fluid in it, tendon goes whacky and makes space for neurovascular (nerves/blood vessels) infiltration, nerve endings turn to into nociceptors, tendon gets painful. Optimal load pushes fluid out, closes the space, tendon calms down, blood vessels/nerves get kicked out. (Warning, that was EXTREMELY DUMBED DOWN, do not use that paragraph in public, please read more on tendinopathy to see how complex it actually is, how much we’ve found out and how much we don’t know.)
As with Tennis Elbow where we want to avoid wrist flexion with load to avoid ‘internal compression’ of the tendon, with Golfers Elbow we want to avoid wrist extension initially whilst we load the tendon using an exercise called an “isometric” which is where you load the soft-tissues but don’t move the joint.
Strength vs Resistance Exercises — Force Production
Although we measure ‘force production’ whlist undertaking a optimal tendon loading program the exercises are not ‘strength’ exercises, no patient gets stronger. Instead they are ‘resistance’ exercises that can increase the pain-free force production of whatever movement they’re targeting. This is important for many reasons, one of which is avoiding the nocebic narrative/language of “weakness”, another reason is in the prescription of the exercises, it differs from usual S&C prescription. I apply this not only to Golfers Elbow, but also many other parts of the body where there is temporary reduction in force production due to pain inhibition and some sort of exercise makes the patients force production better (without an actual ‘strength’ increase).
Phase 1: Isometric / Load & Hold
For this I use the below “wrist flexion load and hold” exercise, holding a weight in the supinated (palm up) hand with the elbow supported on their lap or on a bench, with the wrist straight (neutral). I load up the patient with a dumbbell that makes them “feel it” in the medial elbow but not too painful (<2/10 pain), if they can’t feel it, it needs to be heavier.
Prescription of this exercise is different for every patient (which is why it’s so important people seek help from the appropriate healthcare professional), but I usually start off with: 3x20sec holds (with 10sec rest), x 3 over the day, using a weight that makes them “feel it” in their medial elbow.
For new-grads out there needing an idea of what weight to start with, here’s a little table that may be of assistance to get you in the ballpark, based on what the patients pain-free WF-FP is:
This exercise, coupled with Activity Modification, I think is the most important part of early phase rehab.
In acute cases (< 3months) in patients who aren’t pretty strong (<25kg wrist flexion) this early management might be all that is needed to settle the condition down. What I’ve also found (see below case studies) is that if you are getting >80% difference between WF-FP and you apply Phase 2 in those who are <25kg peak WF normally it may cause them to exacerbate their elbow.
However, in those who require more force production in their wrist flexors and are >28–30 wrist flexion peak force usually, they may require phase 2.
Phase 2: Isotonic (Load and Move)
Again, exercise prescription depends on the patient as every patient and elbow is different. However as a rough guide to prescription for wrist flexion isotonics I’d start with 3 sets of 8–12 reps, slow tempo (2secs each way) 1 min rest between sets, 1–2 reps left in the tank during each set, with a weight that makes them “feel it” in the elbow. They will do this every other day, whilst doing the isotonics every day still.
For those who have ready my blog on Tennis Elbow, note how Phase 2–3 are swapped. This is because I feel CFT is more of a ‘pure tendon’ than the common extensors tendon at the lateral elbow in its role of force production.
Again, reinforce to the patient any Activity Modification advice at this stage but we will also be gradually bringing back any sports/exercise and functional/occupational loads that have been avoided initially.
Very rarely, as those who need it are already doing it, I’ll move to Phase 3
Phase 3 — Dynamic isometric Wrist flexor loads (hold it but move everything else)
As with tennis elbow, Phase 3 involves using this muscle/tendon group to stabilise the wrist whilst moving the rest of the arm against resistance, starting with more compound movements with the wrist flexors working in a dynamic isometric role (eg: flys) then progressing to more isolated but still dynamic isometric tasks (eg: bicep curls).
What about the rest of “Physiotherapy”?
At this point, you may be wondering: Where’s the massage, stretches, dry needling, ultrasound, cupping, scraping? Where’s the manual therapy? Where’s the hands-on stuff? “Where do I aim my massage gun?”
Good questions.
Personally, I utilise manual therapy techniques if I feel the human being in front of me needs it (lnot the condition itself), whether it’s for a short-term analgesic/pain-relief effect, or whether it’s for therapeutic alliance (fancy term for ‘improving patient-physio relationship’). My go-to would be Soft Tissue Massage of the wrist flexors (not the tendon) and maybe passive ultrasound of the medial epicondyle (if it’s a bony-attachment/enthesopathy), otherwise if the patient doesn’t expect it and doesn’t want it I don’t do it and I crack-on with the activity modification/optimal load part of the rehab.
I certainly avoid adjunct treatments that can cause harm in this condition. Stretches that might cause internal compression, I avoid. Dry needling a tendon, I avoid. Rubbing a tendon, I definitely avoid, all tendons hate it…. even if it “feels tight”, don’t touch it.
Case Studies
Case study disclaimer: these are three cases that represent probably 80% of golfers elbow presentations, non-acute/insidious onset with a clear mechanism of injury. Management of cases that do not fit into a similar category will require different management. If you are someone with medial elbow pain (or any pain really), please see a registered and regulated healthcare professional (eg: Physiotherapist, GP, Sports and Exercise Physician, Orthopaedic Specialist) for a full assessment before trialling any of the exercises or management techniques discussed below.
The patients from the below case studies have been deidentified and have consented to having their case written up and presented. Many thanks to them.
Tennis-Golfers Elbow Gary (not his real name)
Gary was in his 50–60s, a left-handed male masters advanced tennis player, ex state player as a junior, who when seeing me had medial elbow pain for 6 months which started when he was getting back into tennis after a long hiatus and was hitting more, including ball machine use and coaching.
He was playing on synthetic grass courts, often with used old balls, mostly doubles but aiming to get into singles, using a >330g racquet with strings >54lbs tension, utilising an eastern forehand grip (old school).
His GP ordered an Xray after 4 months which found “a tiny calcific density projected adjacent the medial epicondyle likely reflecting a small focus of calcific tendinopathy in the common flexor tendon origin”). After 5 months his GP ordered an Ultrasound + cortisone injection (if needed). The ultrasound found a hypoechoic cleft 9x2mm which was reported by the sonographer/radiologist as a “possible tear”, as ultrasound companies often do they offered a cortisone injection (hopefully not into the tendon as that would not be good practice, they tend to make tendons weaker and tear more.. so not sure what the plan was there).
After he did not improve his Tennis Coach recommended he see me.
On assessment:
- Full pain-free wrist and elbow range of movement, cervical spine and shoulder clear.
- WF-FP (wrist flexion force production) was right (unaffected, non-dominant) 18kg , left (affected, dominant)12kg and pain. (60% diff)
- Pain located mid-portion common wrist flexor tendon
Diagnosis: Golfers Elbow (mid-portion)
Management:
Yes… I wrote out all those tennis specific things from his subjective assessment because they all contributed. Here is a screenshot of his activity modification/education:
Yep, it’s a lot. Don’t freak out, if you don’t know much about tennis are a Clinician with a tennis player like Gary in front of you, please feel free to get in touch. I’m always happy to assist Clinicians who are treating tennis players to walk them through what to watch out for.
For his optimal tendon load I gave him 5kg wrist flexion load and hold isotonics. I did some wrist flexor muscle massage for 10mins or so and had a good old-fashioned chin-wag in the name of therapeutic alliance however with the narrative of “this might help it feel better” and that’s it, nothing specific.
On 2nd assessment at week 2:
- WF-FP was right (unaffected, non-dominant) 25kg , left (affected, dominant)18kg and pain. (72% diff)
I had him gradually increasing his tennis load again and added in isotonics (load and move — phase 2).
On 3rd assessment at week 4:
- WF-FP was right (unaffected, non-dominant) 25kg , left (affected, dominant)25kg and pain.
By then he had made all the tennis-specific change I had recommended and he was playing more singles tennis than doubles and was pain-free.
I discharged him after 3 sessions and 6 weeks.
Gym-Golfers Elbow Barry (not his real name)
Barry was a 20–30 year old body builder and concreter with massive arms.
He had right medial elbow pain for a couple of months on and off and it was getting worse recently with supinated loads (palm-up, eg: biceps curl).
He had just finished a body building competition and was also working a fair bit using a trowel in the right hand as a concreter, putting repetitive valgus loads on his elbow at work.
On assessment:
- Full Elbow/Wrist ROM, cervical spine and shoulder clear.
- His pain was located at the common wrist flexor tendon at the medial elbow 1inch distal to the medial epicondyle.
- WF-FP test: Left (unaffected) 45kg, Right (affected, dominant) 35kg (WF-FP% 77%)
No doubt at this point I’m thinking: “oh boy, we need big loads to sort this one out”.
I prescribed 11–14kg isometric holds (depending on what he “felt” each session) and helped him identify the loads that stirred it up so he could dial them back, in this case: Trowelling at work, supinated loads in the gym.
For in-clinic treatment we had a great chat about the world whilst I did some soft-tissue work in the wrist flexors.
I saw him again 2 weeks later, his %WF-FP had improved to 100% (37/37kg) which shows the importance of collecting both arms and comparing the two, otherwise you’d be worried about there being no improvement in gross force production scores. However, his pain had also moved from being a mid-portion tendon pain to an enthesis/bony-attachment pain. Based on this we dialled back the wrist flexor tendon loading and reinforced that even if the load is less (8kg instead of 14kg) he still must load up using a weight where he can “feel it”.
I saw him for a 3rd time 3 weeks later, and he was completely fine on assessment. He had started to dial up gym loads and work loads again as a result. He was 41kg(affected)/38kg(unaffected) on the WF-FP test (108%).
He did in fact mention that he would, every now and then, get a shooting twinge in the ulnar side of his forearm up to his ulnar-side of hand when doing big upper limb loads in the gym, but it’s rare and doesn’t bother him too much. I educated him on the ulnar nerve and how it’s the “funny bone” nerve in the elbow and if it starts happening more frequently or gets more symptomatic to come back in and get it checked.
I discharged him after 3 sessions and 5 weeks.
Chronic Golfers Elbow Craig (not his real name)
The final case is a gem.
30–45yo male with left medial elbow pain for 3 years. Originally from going hard in the gym.
Chronic Craig had seen previous Physios for “Physio” which included heaps of Manual Therapy and adjuncts, and some sort of rehab that didn’t work. Eventually ended up under the care of a Sports Doctor and Orthopaedic Specialist who recommended PRP and then ATI (stem-cell) injections (the latter is pretty expensive).
By the looks of things had spend the above time constantly rubbing the medial elbow and focusing on the idea that there was “scar tissue” that needed a mechanical stimulus to get rid of it. He reported his Sports Doctor had said he’d need surgery if the PRP and ATI injections didn’t work.
On assessment.
- Full Elbow/Wrist ROM, cervical spine and shoulder clear.
- His pain was located at the common wrist flexor tendon at the medial elbow 1inch distal to the medial epicondyle.
- Right (unaffected, dominant) WF-FP 26kg and left (affected, non-dominant) WF-FP 12kg (42%).
Initial management consisted of:
- Stopping him rubbing and poling the medial elbow constantly.
- 4kg Load and Holds, 3sets of 20secs, x3/day
2 weeks later:
- Chronic Craig had increased his load and holds up to 7kg, 4sets of 30secs, x3/day.
- He had right (unaffected, dominant) WF-FP 34kg and left (affected, non-dominant) WF-FP 20kg (58%).
We persisted with phase 1 rehab.
At week 5 (3 weeks later) he came back in and was going well:
- He had right (unaffected, dominant) WF-FP 30kg and left (affected, non-dominant) 24kg (80%) and it was pretty much his max strength.
We commenced phase 2 rehab, slow “up and downs” (isotonic wrist flexion), with 3 sets of 8–12 reps with a weight that that made him “feel it” in his medial elbow (5–7kg), every other day.
I advised him he can maintain this improvement with 3–4x/week of upper limb resistance training, non-specific… just push/pull tasks forwards and overheads.
Quick discussion about these cases
These three cases were very clear and simple Tendinopathy cases. There was no other conditions affecting the medial elbow which made management very simple. There was a gradual overload mechanism of injury rather than acute trauma, which again makes management much easier. What these cases do have in common is that the key to treatment is education/advice (activity modification) and optimal tendon load.
My process of assessment and management of Golfers Elbow may not work for 100% of cases however as with management of every musculoskeletal condition, management is subtly (or sometimes not so subtly) different for every patient that walks in the door.
Summary
Much like the Tennis Elbow blog I’ve written, I hope this write-up assists patients and clinicians out there in their management of Golfers Elbow. I’ve found this simple process of managing Golfers Elbow has helped myself and my patients avoid going down unnecessary rabbit holes during diagnosis and management. Patients have found it easy to understand and are always surprised when the “simple stuff works the best”.
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References
Amin, N. H., Kumar, N. S., & Schickendantz, M. S. (2015). Medial epicondylitis: evaluation and management. JAAOS-Journal of the American Academy of Orthopaedic Surgeons, 23(6), 348–355.
Batt, M. E. (1993). Golfing injuries. An overview. Sports Medicine (Auckland, NZ), 16(1), 64–71.
Bisset, L. M., & Vicenzino, B. (2015). Physiotherapy management of lateral epicondylalgia. Journal of physiotherapy, 61(4), 174–181.
Ciccotti, M. G., & Ramani, M. N. (2003). Medial epicondylitis. Sports Medicine and Arthroscopy Review, 11(1), 57–62.
Cook, J., & Purdam, C. R. (2009). Is tendon pathology a continuum? A pathology model to explain the clinical presentation of load-induced tendinopathy. British journal of sports medicine, 43(6), 409–416.
Cook, J. L., & Purdam, C. (2012). Is compressive load a factor in the development of tendinopathy? British journal of sports medicine, 46(3), 163–168.
Descatha, A., Leclerc, A., Chastang, J.-F., & Roquelaure, Y. (2003). Medial epicondylitis in occupational settings: prevalence, incidence and associated risk factors. Journal of occupational and environmental medicine, 45(9), 993.
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