Golfer's Elbow: Understanding, Treatment, and the Indispensable Role of Physiotherapy
▫️Written by John Keller
✅ Reviewed by Dr. Jenny Hynes on October 19, 2023
Medial epicondylitis, also known as “golfer’s elbow” or “thrower’s elbow”, refers to the chronic tendinosis of the flexor-pronator musculature insertion on the medial epicondyle of the humerus as a result of overuse or repetitive stress. It is more than a mere inconvenience. It represents a source of ongoing discomfort, a subtle yet insistent reminder every time one reaches, grasps, or grips. Many might attribute it exclusively to the golfing community, but its reach is far more extensive, affecting those from diverse walks of life engaged in repetitive wrist and hand motions.
Also termed media epicondylosis or epicondylalgia, recent developments in our understanding of Golfer's Elbow have shown that it's not merely an inflammatory condition. Instead, it's predominantly degenerative, a result of tendon pathology (Cook & Purdam, 2009). The tendons of the forearm, under consistent strain, develop microtears, leading to discomfort and pain around the inner elbow. If overlooked or mismanaged, the repercussions can span from persistent pain to significant functional impairment.
In the sports world, it can be seen in throwing athletes (baseball pitchers, javelin throwers), golfers, tennis players, bowlers, rock climbers, archers, and weightlifters. However, most commonly it occurs in golfers, tennis players, and baseball pitchers. Although it is often associated with athletes, this condition is also prevalent in the general population, commonly seen in carpenters, utility workers, butchers, and caterers.
This is where physiotherapy takes center stage. Physiotherapy's role in the treatment and mitigation of Golfer's Elbow symptoms is paramount. Not only does it focus on rehabilitating the affected area, but it also equips individuals with strategies to prevent further damage. By introducing targeted exercises and stretches, physiotherapists pave the path towards strength restoration, flexibility enhancement, and joint function improvement (Bisset et al., 2015).
Unraveling Golfer's Elbow
Golfer's Elbow, a term familiar to many yet fully understood by few, stands as a testament to the complexities of our musculoskeletal system. In its simplest essence, Golfer's Elbow refers to the wear and tear of the tendons that connect the forearm muscles to the bony bump on the inner elbow. The flexor carpi radialis and the pronator teres are the most commonly involved tendons in medial epicondylitis (Ollivierre et al., 1995). These tendons, much like the ropes in a pulley system, facilitate the movement and strength of our hands and wrists. Over time, with excessive use or strain, they can start showing signs of distress.
Although termed epicondylitis, a more appropriate description, especially in a chronic setting, would be epicondylosis or epicondylalgia. Current literature shows that the underlying process appears to be degeneration and granulation tissue formation that is referred to as “angiofibroblastic hyperplasia or tendinosis” without the presence of a definitive inflammatory process. However, it should be noted, that there is no clear evidence that the early stages of the condition do not have an inflammatory component (Donaldson et al., 2014).
Repetitive gripping and wrist motions, such as those in swinging a golf club, handling tools, or even consistently using a computer mouse, exert a strain on these tendons. The accumulation of this strain can lead to microtears within the tendon structure. These microtears, if perpetually aggravated, can culminate in symptoms characteristic of Golfer's Elbow: pain radiating from the inner elbow, tenderness to touch, and a weakening grip strength (Cook & Purdam, 2009).
The implications of such a condition extend beyond mere discomfort. For individuals who rely on hand and wrist activities for their professions – be it carpenters, chefs, or computer professionals – Golfer's Elbow can be severely problematic. A weakened grip or persistent pain can hinder tasks we often take for granted: turning a doorknob, lifting grocery bags, or even holding a coffee mug. Such disruptions underscore the profound influence of this condition on our daily lives.
Timely intervention becomes paramount. If left unchecked, the symptoms can progress from episodic flare-ups to persistent pain, potentially leading to long-term functional impairments. The evidence suggests that early recognition and appropriate management can not only alleviate symptoms but also significantly reduce the risk of recurrence (Bisset et al., 2015).
Understanding medial epicondylitis’ intricacies is the cornerstone to proactive management. This condition serves as a reminder that the rigors of our daily activities, even seemingly innocuous ones, can have profound effects on our health. Recognizing the signs and seeking timely care can make all the difference.
Causes and Risk Factors of Golfer's Elbow
Golfer's Elbow is often misinterpreted as a condition exclusively for golfers, but the reality is much broader. At the root of Golfer's Elbow lies the repetitive flexion (bending) of the wrist and forceful gripping activities. When these actions are repeated often, it puts excessive strain on the tendons of the inner elbow, leading to the aforementioned microtears and associated pain (Cook & Purdam, 2009).
While golfers are certainly among the affected, many other activities and professions bring about a heightened risk for developing this condition:
Occupational Risks: Jobs that demand repetitive wrist motion or gripping, such as carpentry, painting, or even extended computer usage, can heighten the risk. Medial epicondylitis is often precipitated by poor body mechanics, improper techniques, and/or inadequate equipment or tools (Ciccotti et al., 2004).
Sports: Outside of golf, sports like tennis, baseball, weightlifting, and even archery can also contribute due to the consistent wrist motion they entail (Peterson & Renström, 2017). The intense valgus forces during the late cocking and acceleration phases of throwing or the late phases of the golf swing just before and during contact with the ball or ground contribute to the prevalence among these athletes (Amin et al., 2015).
To reduce the risk or manage the early stages of Golfer's Elbow:
Regular Breaks: It's been shown that incorporating regular breaks in tasks that involve sustained wrist use can alleviate constant tendon stress (Barr & Barbe, 2002).
Strengthening Exercises: Engaging in specific exercises can fortify the forearm tendons. A stronger muscle base coupled with a tendon loading program can offset some strain from the tendons, offering a protective effect (Magee, 2014).
Ergonomic Adjustments: For desk-bound professionals, ergonomic workstations, including wrist rests and ergonomic mouse designs, can minimize the strain, as documented by several occupational health studies (Rempel et al., 2008).
Technique Matters: In sports or work, adhering to proper techniques is a practical measure to avert undue stress on the forearm and wrist (Walker-Bone et al., 2004). Having a club professional or coach assess hand or wrist position, along with other upper body biomechanics while hitting or lifting can decrease the risk of medial epicondylitis.
Understanding the causes and risks of Golfer's Elbow provides a foundation for proactive management. By integrating simple measures into daily routines, one can mitigate potential risks and ensure healthier forearm function.
Recognising the Signs of Golfer's Elbow
Golfer's Elbow, medically known as medial epicondylitis, epicondylosis or epicondylalgia, exhibits several distinctive signs and symptoms. The most prominent is pain and tenderness localized at the inner part of the elbow. This pain often intensifies with specific movements, such as gripping objects or wrist flexion, and can radiate down the forearm towards the wrist (Nirschl & Ashman, 2003).
Differentiating Golfer's Elbow
Misconceptions abound when it comes to conditions affecting the elbow. A frequent mix-up is between Golfer's Elbow and conditions like cubital tunnel syndrome. While both involve medial elbow pain, they have distinct differences:
Golfer's Elbow (Medial Epicondylitis): Primarily affects the tendons on the inner elbow, with pain sometimes radiating down the forearm. The primary cause is strain due to repetitive wrist and gripping activities (Kraushaar & Nirschl, 1999).
Cubital Tunnel Syndrome: This is characterized by compression or irritation of the ulnar nerve in an area known as the cubital tunnel, located just behind the inner elbow. Its symptoms may include tingling and numbness in the ring and small fingers and a weakness in hand grip (Andrews et al., 2018).
It's crucial to not self-diagnose based on symptoms alone. While understanding the signs is essential, seeking the expertise of healthcare professionals ensures accurate diagnosis and appropriate treatment. Clinics, such as Keilor Road Physiotherapy, offer assessments and treatments tailored to individual needs. An expert evaluation can make a marked difference in recovery trajectories and help navigate the nuances of similar conditions (Palmer & Hughes, 2010).
Prevention Strategies for Golfer's Elbow
One of the foremost strategies in preventing Golfer's Elbow is ensuring proper technique during activities that involve gripping or wrist movement. Whether it's swinging a golf club, pitching a baseball, lifting weights, or simply using hand tools, the correct technique can significantly reduce undue stress on the tendons (Kraushaar & Nirschl, 1999). For example, in a tennis player, a larger grip size on the racquet, stringing the racquet less tight, and improving the serve and forehand techniques may help reduce the stress on the flexor-pronator mass (Ciccotti et al., 2004).
It's not always intuitive to know the best postures or techniques for specific activities. Keilor Road Physiotherapy can offer guidance on biomechanics, ensuring movements align with the body's natural function and minimizing risks (Magee, 2014).
Incorporate Wrist and Tendon Exercises:
Wrist Exercises: Gentle exercises can help strengthen wrist and forearm muscles, offering better support to tendons.
Tendon Loading Exercises: Isometric exercises, where the muscle does not change its length during contraction, can assist in tendon strengthening (Rio et al., 2015).
Stretching: Regularly stretching the forearm muscles can increase flexibility and reduce tension on tendons.
Warming Up: A proper warm-up prepares muscles and tendons for activity, making them less prone to injury (Thacker et al., 2004).
The adage "prevention is better than cure" holds especially true for conditions like Golfer's Elbow. Recognize early signs and prioritize self-care. Incorporating preventative exercises into your routine, seeking timely professional guidance, and listening to your body are essential steps. Keilor Road Physiotherapy can assist in both preventive strategies and interventions, ensuring optimal elbow health.
Treatment Options for Golfer's Elbow
When addressing Golfer's Elbow, an early and non-invasive approach often yields the best results:
Rest
A period of rest is fundamental in allowing inflamed or irritated tendons the opportunity to heal (Nirschl & Ashman, 2003).
Ice
Applying ice can help reduce inflammation and offer symptomatic relief, especially in the initial stages post-injury (Bleakley, McDonough, & MacAuley, 2004).
Anti-Inflammatory Medications
Over-the-counter anti-inflammatory drugs, such as ibuprofen, can assist in reducing pain and inflammation. Always consult with a healthcare professional before starting any medication regimen (Coombes et al., 2010).
Activity Modification
Adjusting or limiting activities that aggravate the condition can contribute significantly to the recovery process (Kraushaar & Nirschl, 1999).
Bracing and Splinting
Using a brace or splint can provide needed support to the affected area, minimizing strain on the tendon and facilitating recovery (Biber et al., 2010).
Corticosteroid Injections
For cases where symptoms persist, corticosteroid injections might be considered. They can offer temporary relief, though their long-term effectiveness remains a topic of discussion (Coombes, Bisset, & Vicenzino, 2010).
Surgery
Surgery is typically not required. However, if no benefit is seen with the above conservative treatments for 6 to 12 months, then surgical management may be considered (Donaldson et al., 2014).
The Crucial Role of Physiotherapy
Physiotherapy stands out as an effective, non-invasive modality for managing Golfer's Elbow. Keilor Road Physiotherapy offers tailored physiotherapy regimens that address the root causes, improve flexibility, and strengthen the affected area. It's an integrated approach, balancing manual techniques with exercise regimens to ensure a holistic recovery (Bisset et al., 2006).
Physiotherapy's Role in Managing Golfer's Elbow
Tendon Loading and Isometrics
Current literature underscores the importance of tendon loading in managing tendinopathies like Golfer's Elbow. Isometric exercises, wherein the muscle contracts without notable length change, have been shown to both reduce pain and aid in tendon repair. These exercises are typically the first step in a phased rehabilitation approach, providing immediate relief and preparing the tendon for more demanding activities (Rio et al., 2015).
Progression to Stretching and Resistance Exercises
Following isometrics, physiotherapists often progress to dynamic loading through resistance exercises. Eccentric (muscle lengthening under load) exercises, in particular, are advocated for their ability to promote collagen alignment within the tendon, facilitating repair and strengthening (Malliaras et al., 2013). Combined with stretching routines that improve muscle-tendon flexibility, this comprehensive approach addresses both pain relief and functional recovery.
Progressive Reintegration
The pathway back to full, uninhibited activity, whether in sports or occupation-specific tasks, is paved with gradual and intentional progressions. Once a patient can execute repetitive exercises without discomfort—a milestone indicative of the tendon’s increased capacity to manage load—they are eased back into activities reflective of their specific sports or occupational demands. This deliberate reintegration allows the tendon to adapt progressively to the mechanical demands and complexities of the activity, safeguarding against abrupt overload (Malliaras et al., 2015).
Sports/Occupation-Specific Activities
Return to sport or work is not a simple leap but rather a continuum, wherein the patient is guided through activities that progressively mirror the demands of their target activity. This phase, often orchestrated by the physiotherapist, may involve activities that simulate the specific mechanical and physiological requirements of their sport or job, gradually scaling in intensity and complexity while meticulously monitoring for any signs of tendon distress (Silbernagel, Thomeé, & Karlsson, 2007).
Transition to a Maintenance Exercise Program
The completion of guided therapy is not the end, but rather a transition. Patients are typically ushered into a maintenance exercise program, designed to sustain overall flexibility and strength. This program, structured to ensure that the tissues remain robust and resilient, plays a pivotal role in reducing the risk of recurrence, maintaining tendon health, and securing long-term functional capacity (Cook & Purdam, 2009).
When combatting the discomfort of Golfer's Elbow, a multi-faceted physiotherapy approach is often employed. Techniques such as manual therapy are vital in facilitating joint mobility, alleviating pain, and optimising movement patterns. Soft tissue mobilisation can specifically address muscle tightness and tissue adhesions, playing a pivotal role in alleviating localized discomfort and restoring range of motion. Furthermore, muscle-strengthening routines are integral, fortifying the forearm muscles, reducing tendon strain, and promoting functional recovery (Bisset et al., 2005; Coombes et al., 2015).
Keilor Road Physiotherapy remains attuned to the latest evidence-based practices in treating Golfer's Elbow. They emphasize a structured progression from isometric loading to dynamic resistance exercises, ensuring that the tendon is not just relieved of pain but also rehabilitated to its optimal function. Their approach, firmly grounded in current research, ensures that patients receive cutting-edge care, maximizing recovery potential.
Navigating from the acute phase of Golfer's Elbow through to a safe and effective return to activity, and eventually into a preventative maintenance phase, encapsulates a journey of recovery and resilience. Each phase, orchestrated and informed by evidence-based practices, ensures that the individual not only regains their pre-injury function but is also empowered with strategies to safeguard against future injury.
The transformative power of physiotherapy goes beyond merely symptom relief. Through structured interventions and exercises, it aims to restore optimal function, ensuring patients can resume their daily tasks, sporting activities, and occupational demands without hinderance. Ultimately, physiotherapy plays a paramount role in enhancing quality of life by minimizing pain, optimizing function, and fostering independence (Coombes et al., 2015).
Conclusion
Golfer's Elbow, throwers elbow, medial epicondylitis – whichever term you use to describe it, while a common affliction, does not necessitate a compromised quality of life. As discussed throughout this article, the complexities of this condition emerge not only from repetitive wrist and gripping motions but also from myriad daily activities and occupational demands (Nirschl & Ashman, 2003). Understanding these complexities is the first step toward effective intervention.
Seeking timely and appropriate medical care remains essential. However, it's the integration of physiotherapy techniques — from isometric tendon loading, soft tissue mobilisation, to tailored exercise regimens — that often delineates the path to recovery. Such techniques, grounded in evidence, have been showcased to alleviate symptoms, restore functionality, and ultimately, uplift the quality of life (Bisset et al., 2005; Coombes et al., 2015).
With proactive measures, early intervention, and the dedicated support of physiotherapy professionals, like those here at Keilor Road Physiotherapy, the journey from injury to full recovery is not only feasible but also promising. Your normal activities, hobbies, and passions await you on the other side of recovery, and with the right strategies and support, you're well-equipped to reach that destination.
References
Amin NH, Kumar NS, Schickendantz MS. Medial epicondylitis: evaluation and management. J Am Acad Orthop Surg. 2015 Jun;23(6):348-55.
Andrews, K., Rowland, A., Pranjal, A., & Ebraheim, N. (2018). Cubital tunnel syndrome: Anatomy, clinical presentation, and management. Journal of orthopaedics, 15(3), 832–836. https://doi.org/10.1016/j.jor.2018.08.010
Barr, A.E., & Barbe, M.F. (2002). Pathophysiological tissue changes associated with repetitive movement: a review of the evidence. Physical therapy, 82(2), 173-187.
Biber, R., & Gregory, A. (2010). Overuse injuries in youth sports: is there such a thing as too much sports?. Pediatric annals, 39(5), 286–292. https://doi.org/10.3928/00904481-20100422-09
Bisset, L., Beller, E., Jull, G., Brooks, P., Darnell, R., & Vicenzino, B. (2006). Mobilisation with movement and exercise, corticosteroid injection, or wait and see for tennis elbow: randomised trial. *BMJ, 333*(7575), 939.
Bisset, L., Beller, E., Jull, G., Brooks, P., Darnell, R., & Vicenzino, B. (2015). Physiotherapy management of lateral epicondylalgia. *Journal of Physiotherapy, 61*(4), 174-181.
Bisset, L., Paungmali, A., Vicenzino, B., & Beller, E. (2005). A systematic review and meta-analysis of clinical trials on physical interventions for lateral epicondylalgia. *British Journal of Sports Medicine, 39*(7), 411-422.
Bleakley, C., McDonough, S., & MacAuley, D. (2004). The use of ice in the treatment of acute soft-tissue injury: a systematic review of randomized controlled trials. *The American journal of sports medicine, 32*(1), 251-261.
Ciccotti MC, Schwartz MA, Ciccotti MG. Diagnosis and treatment of medial epicondylitis of the elbow. Clin Sports Med. 2004 Oct;23(4):693-705, xi.
Coombes, B. K., Bisset, L., & Vicenzino, B. (2015). Management of Lateral Elbow Tendinopathy: One Size Does Not Fit All. The Journal of orthopaedic and sports physical therapy, 45(11), 938–949. https://doi.org/10.2519/jospt.2015.5841
Coombes, B.K., Bisset, L., & Vicenzino, B. (2010). Efficacy and safety of corticosteroid injections and other injections for management of tendinopathy: a systematic review of randomised controlled trials. *Lancet, 376*(9754), 1751-1767.
Cook, J.L., & 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.
Donaldson O, Vannet N, Gosens T, Kulkarni R. Tendinopathies Around the Elbow Part 2: Medial Elbow, Distal Biceps and Triceps Tendinopathies. Shoulder Elbow. 2014 Jan;6(1):47-56.
Kraushaar, B.S., & Nirschl, R.P. (1999). Tendinosis of the elbow (tennis elbow). Clinical features and findings of histological, immunohistochemical, and electron microscopy studies. *The Journal of bone and joint surgery. American volume, 81*(2), 259-278.
Magee, D.J. (2014). *Orthopedic physical assessment*. Elsevier Health Sciences.
Malliaras, P., Barton, C.J., Reeves, N.D., & Langberg, H. (2013). Achilles and patellar tendinopathy loading programmes: a systematic review comparing clinical outcomes and identifying potential mechanisms for effectiveness. *Sports Medicine, 43*(4), 267-286.
Malliaras, P., Cook, J., Purdam, C., & Rio, E. (2015). Patellar tendinopathy: clinical diagnosis, load management, and advice for challenging case presentations. *Journal of Orthopaedic & Sports Physical Therapy, 45*(11), 887-898.
Nirschl, R.P., & Ashman, E.S. (2003). Elbow tendinopathy: tennis elbow. *Clinics in sports medicine, 22*(4), 813-836.
Ollivierre CO, Nirschl RP, Pettrone FA. Resection and repair for medial tennis elbow. A prospective analysis. Am J Sports Med. 1995 Mar-Apr;23(2):214-21
Palmer, B. A., & Hughes, T. B. (2010). Cubital tunnel syndrome. The Journal of hand surgery, 35(1), 153–163. https://doi.org/10.1016/j.jhsa.2009.11.004
Peterson, L., & Renström, P. (2017). Sports injuries: Their prevention and treatment. Taylor & Francis.
Rempel, D., Keir, P.J., Bach, J.M., & Gordon, G. (2008). Effect of wrist posture on carpal tunnel pressure while typing. Journal of Orthopaedic Research, 26(9), 1269-1273.
Rio, E., Kidgell, D., Purdam, C., Gaida, J., Moseley, G.L., Pearce, A.J., & Cook, J. (2015). Isometric exercise induces analgesia and reduces inhibition in patellar tendinopathy. *British Journal of Sports Medicine, 49*(19), 1277-1283.
Silbernagel, K.G., Thomeé, R., & Karlsson, J. (2007). Full symptomatic recovery does not ensure full recovery of muscle–tendon function in patients with Achilles tendinopathy. *British Journal of Sports Medicine, 41*(4), 276-280.
Thacker, S.B., Gilchrist, J., Stroup, D.F., & Kimsey, C.D. (2004). The impact of stretching on sports injury risk: a systematic review of the literature. *Medicine & Science in Sports & Exercise, 36*(3), 371-378.
Walker-Bone, K., Palmer, K.T., Reading, I., Coggon, D., & Cooper, C. (2004). Prevalence and impact of musculoskeletal disorders of the upper limb in the general population. Arthritis & Rheumatism, 51(4), 642-651.
Article by
John Keller
Clinical Director | Sports & Musculoskeletal Physiotherapist
John graduated as a Physiotherapist from the Auckland University of Technology with the John Morris memorial prize for outstanding clinical practise in 2003. John has since completed Post Graduate Diplomas in both Sports Medicine and Musculoskeletal Physiotherapy with distinction, also collecting the Searle Shield for excellence in Musculoskeletal Physiotherapy.
Reviewed by
Dr. Jenny Hynes FACP
Clinical Director | Specialist Musculoskeletal Physiotherapist
Jenny sat extensive examinations to be inducted as a fellow into the Australian College of Physiotherapy in 2009 and gain the title of Specialist Musculoskeletal Physiotherapist, one of only a few physiotherapists in the state to have done so.