Physical Therapy for Golfer’s Elbow
Physical Therapy for Medial Epicondylitis
What is golfer's elbow?
Golfer's elbow is a condition that involves inflammation of the tendons on the medial (inner) side of the elbow. The wrist flexor and forearm pronator tendons are involved in this condition.
Image from SoundPain Alliance
Symptoms of golfer's elbow include:
Pain and tenderness on the inner side of the elbow
Stiffness in the elbow
Pain that may radiate down the forearm
Weakness in the grip
Golfer's elbow is also referred to as medial epicondylitis. An -itis refers to when something is inflamed. However, golfer’s elbow is the type of medial elbow pain that typically comes on gradually from overuse. As a result, the more appropriate term to use is medial epicondylalgia (pain of the medial elbow). There are some circumstances in which there really is an -itis, and the differences will be discussed throughout this blog.
What causes golfer’s elbow?
Golfer's elbow is primarily caused by repetitive stress or overuse of the muscles and tendons in the forearm that attach to the medial epicondyle of the elbow. Here are some common causes:
Repetitive Motion: Engaging in activities that involve frequent gripping, swinging, or twisting motions, such as golf, tennis, or baseball, can strain the tendons. The repetitive stress can lead to tiny tears and inflammation.
Poor Technique: In sports like golf or tennis, improper technique can place excessive strain on the elbow. For instance, an incorrect grip or swing can contribute to overuse injuries.
Overuse: Performing repetitive tasks, whether in sports or in daily activities like typing or using hand tools, can lead to chronic stress on the tendons.
Weak Forearm Muscles: Insufficient strength or flexibility in the forearm muscles can increase the risk of developing golfer’s elbow. Weak or imbalanced muscles may not adequately support or absorb the stress placed on the tendons.
Age: As people age, the tendons become less flexible and more susceptible to injury. Degenerative changes in the tendons can make them more prone to inflammation and pain.
Underlying Medical Conditions: Conditions such as rheumatoid arthritis or diabetes can affect tendon health and contribute to the development of golfer’s elbow.
Proper technique, strength training, and preventive measures can help reduce the risk of golfer’s elbow.
How to diagnose golfer’s elbow?
We utilize a few clinical tests to help diagnose golfer’s elbow. The 2 main tests include a resisted wrist flexion-pronation test and a passive wrist flexor-pronator stretch test.
A resisted wrist flexion-pronation test involves resisting the combined movement of wrist flexion and forearm pronation (with the hand closed in a fist). Reproduction of familiar symptoms in the medial epicondylar region is considered a positive test.
A passive wrist flexor-pronator stretch test involves our therapist straightening your elbow, bending your wrist all the way, and supinating your forearm all the way to maximally stretch the wrist flexors and forearm pronators. Reproduction of familiar symptoms in the medial epicondylar region is considered a positive test.
It must be noted that the subjective history should match with the objective tests for us to feel more confident in making a clinical diagnosis of golfer’s elbow. Our therapists also are sure to screen the joints above and below your elbow, as the wrist, shoulder, and neck can refer symptoms to the medial elbow area. This is crucial in determining the proper diagnosis, and therefore, proper course of physical therapy treatment interventions.
How long does golfer’s elbow take to heal?
Mild cases of golfer’s elbow that are not very irritable and have not lasted multiple months are most likely to get better within a few weeks if the proper course of action is taken with physical therapy. More severe cases of golfer’s elbow that are more irritable, more chronic, will take multiple months (3-12 months) to recover (with proper physical therapy treatment).
It's important to consult with a healthcare provider to get a personalized assessment and treatment plan, as well as to receive guidance on how to safely return to activities.
What is the best treatment for golfer’s elbow?
Best treatment for golfer’s elbow should include exercises for the wrist flexors: isometric, concentric, and/or eccentric exercises, depending on the stage of healing and patient tolerance.
Stretches for the wrist flexors and forearm pronators may be included to increase flexibility.
Shoulder and scapular (shoulder blade) strengthening should be included if strength deficits are identified upon clinical examination, in addition to wrist flexor-pronator strengthening.
Manual therapy joint mobilizations to the elbow can help decrease pain and increase pain-free grip strength, but should be combined with wrist flexor-pronator strengthening exercises. Our physical therapists specialize in these types of manual therapy techniques.
Taping techniques to the elbow may help provide immediate and short-term pain relief and improve pain-free muscle function when symptoms are more irritable.
How to rehab golfer’s elbow?
When we rehab golfer’s elbow, we initially want to temporarily remove or modify activities that are aggravating the elbow pain, such as gripping exercises. Gripping with a pronated grip can be especially painful (more on that below).
Stretching progression (see videos further in the blog for a better visual):
Wrist flexor stretching (start with a bent elbow and progress to an extended elbow)
Lastly, add forearm supination when tolerable.
Strengthening progression:
Start with isometric exercises when symptoms are more irritable. This is when the wrist flexor muscles contract without movement of the wrist.
When tolerated, progress to eccentric wrist flexion strengthening. This is when the wrist flexor muscles contract while they are lengthening (controlling the lowering phase of the movement).
Eccentric wrist flexion exercises of 3 sets of 15 repetitions should be performed daily. Each repetition should take 4 seconds to complete. There should be enough load to induce minimal discomfort during the exercise. Up to 5/10 tendon pain is acceptable during exercise, after exercise, or the next morning. But we do want symptoms back down to baseline by the next bout of eccentric exercise the next day.
According to this study, the addition of eccentric exercises to standard physical therapy reduced pain and improved function more effectively in individuals experiencing persistent golfer’s elbow pain.
Lastly, we progress to isotonic (concentric eccentric) wrist flexor strengthening. This is when we are contracting the wrist flexor muscles on both the up phase (concentric) and the down phase (eccentric).
We also want to strengthen our forearm muscles that perform pronation and supination. We start with the elbow bent and progress to elbows straight as tolerated.
Simultaneously, we want to strengthen any shoulder girdle muscles that are weak upon examination. We commonly find strength deficits in the periscapular muscles (rhomboids, middle trap, lower trap, etc) and the shoulder external rotators (infraspinatus and teres minor).
Rhomboids
Traps
Infraspinatus
Teres Minor
When symptoms are less irritable and impairments have been addressed, we want to gradually reinitiate movements that were previously painful, such as gripping exercises with a pronated grip.
How to wear a golfer's elbow brace?
A golfer’s elbow brace is referred to as a counterforce orthosis. Its purpose is to place pressure on the wrist flexor muscles to prevent load transfer to the medial epicondyle. This allows for temporary offloading of the medial epicondyle and relieves painful symptoms associated with gripping and other functional tasks.
The evidence suggests the use of a brace during activity for immediate improvement of pain and strength in those whose symptoms are aggravated with activity. This is especially true for those who have highly irritable symptoms, and those who have difficulty performing functional activities.
Here is how we suggest you wear a golfer’s elbow brace (the right way):
Image from BRACEABILITY
Do compression sleeves help golfer’s elbow?
The short answer here is no… there is no evidence to suggest that compression sleeves have a positive effect on pain associated with golfer’s elbow. Some patients like to wear them, but it is believed that a placebo effect is influencing their pain experience.
Is ice good for golfer’s elbow?
If you are experiencing true inflammation, then ice can be valuable in the acute phase of rehab (0-72 hours). However, chronic golfer’s elbow pain should not be iced. Typically, there is an overloading of the wrist flexor tendons and a lack of the necessary blood supply to the region. It is suggested that you avoid icing after the acute phase if you are attempting to ice for inflammation (it will not be helpful, and may actually be harmful). We suggest that you use ice after the acute phase only if you are icing for pain relief due to excessive soreness. We know that ice can numb the skin and prevent the potential interpretation of pain. Use for 15-20 minutes at a time when applying ice (do not apply ice in direct contact with your skin).
Is heat good for golfer’s elbow?
Heat for golfer’s elbow does not facilitate true healing, as superficial heat does not get deep enough beneath the skin. However, some patients feel pain relief with heat, so we do recommend its use for temporary/transient pain relief. Use heat for 15-20 minutes at a time, and remember to use the appropriate amount of towels in between your skin and the heating pad to avoid burns to your skin.
Can a TENS unit help golfer’s elbow?
A TENS unit can provide temporary, transient relief from golfer’s elbow. The pain relief will occur while the TENS machine is on, and possibly for 30-60 minutes after the treatment is over. However, TENS does not provide a long term solution to golfer’s elbow pain. It can be a part of a comprehensive treatment plan, and is used before soft tissue mobilization, joint mobilization, and exercise interventions. The type of TENS used is called “Burst TENS.”
Can massage help golfer’s elbow?
Yes- soft tissue mobilization (massage) can, and should be used as part of a comprehensive treatment plan in treating golfer’s elbow. The evidence is more clearly supportive of massaging the muscles. However, there is conflicting evidence on cross friction massage at the tendon. Our therapists advise against it, as it can potentially aggravate your medial elbow pain. We perform soft tissue mobilization as a part of your physical therapy treatment for golfer’s elbow.
Can acupuncture help golfer’s elbow?
There is not much evidence that the traditional, Eastern medical approach to acupuncture treatment is helpful for golfer’s elbow. However, there is moderate evidence to support the use of dry needling for golfer’s elbow. This is when the same type of needles are placed within trigger points throughout the flexor carpi radialis and pronator teres muscles. There isn’t sufficient evidence to outline the optimal dosage parameters for this treatment, though.
How to prevent golfer’s elbow?
You can prevent golfer’s elbow by monitoring your repetitive stress to the wrist flexors. Overloading the wrist flexor muscles will result in more load transfer to the wrist flexor tendons.
The key is to focus on manipulating the variables associated with your training. If that area hurts while performing the exercise, you can consider decreasing the intensity (weight) of the exercise and reassessing how it feels. If you can’t get enough of a training stimulus, this is when you would modify the exercise itself (more on that later).
If you’re experiencing discomfort after your training, then variables like frequency of training and overall volume of training should be considered as potential contributing factors.
Golfer’s elbow is an overuse type of injury, so pay attention to how often you are using tools that demand repetitive motion.
What are the best exercises for golfer’s elbow?
Wrist flexor stretch (elbow bent and progress to elbow straight)
Isometric wrist flexion / eccentric wrist flexion / isotonic (concentric eccentric) wrist flexion
Wrist supination/pronation (with Flexbar)
Quadruped T
Bilateral shoulder external rotation with band
What exercises to avoid with golfer’s elbow
There are a few exercises that we typically recommend that you avoid when you are healing from golfer’s elbow. Exercises that require a lot of gripping, like pull ups, dips, and muscle ups should be avoided until symptoms are less irritable. Then they can be gradually reintroduced to make sure there isn’t an exacerbation of symptoms.
Can I lift weights with golfer’s elbow?
You can lift weights with golfer’s elbow, but you will likely need to modify your grip to a more neutral grip position. Pronated gripping is the most painful and should be temporarily avoided until symptoms are not as irritable.
Pronated Grip
Neutral Grip
Supinated Grip
You will also likely need to modify some of the variables of your lifting, including the intensity (weight), frequency, and overall volume. Our therapists guide you through all this to make sure that you can continue to lift weights while healing from golfer’s elbow.
Closing Remarks
If you would like to work with us to resolve your medial elbow pain, contact us below to speak with a physical therapist.
Disclaimer: This is not intended to be formal medical advice. Your individual needs should be met by the appropriate health care practitioners. Please consult with a trusted provider.
Dr. Vincent Liu PT, DPT
Doctor of Physical Therapy
The Game Plan Physical Therapy