Do you have elbow pain with lifting, gripping, or playing sports?
In this blog, I’m going to discuss golfer’s elbow, dispel the most common myths associated with the diagnosis, and teach you everything you need to know about managing the condition.
Be sure to also check out our Golfer’s Elbow Program!
Elbow Anatomy & Function
To best understand golfer’s elbow, it’s important to briefly review some basic elbow anatomy.
The two bones of the forearm are known as the radius and ulna, while the arm bone is known as the humerus. Together, these three bones form the humeroradial and humeroulnar joints, which make up the elbow.
If you feel the bony prominence on the outside of your elbow, this is a part of your humerus known as the lateral epicondyle. The lateral epicondyle is the location of pain for people who experience tennis elbow.
If you feel a similar bony prominence on the inside of your elbow, this is a part of your humerus known as the medial epicondyle. The medial epicondyle, as you might guess, is the area of pain relevant to golfer’s elbow.
Many of the muscles that control the movements of your forearm, wrist, and fingers attach to the medial and lateral epicondyles via their tendons (because tendons attach muscles to bones).
The muscles that attach to the medial epicondyle have 3 primary actions: finger flexion, wrist flexion, and pronation, which involves turning your palm down toward the floor. If you squeeze your hand into a fist, you should be able to see and feel these muscles contract.
Golfer’s Elbow (or not?)
There are a lot of names used to describe this inner elbow pain: medial epicondylitis, medial epicondylalgia, golfer’s elbow, etc. This can be confusing.
Medial epicondylitis refers to inflammation of the medial epicondyle, or more specifically, inflammation of the tendons that attach to the medial epicondyle. However, medial epicondylitis has fallen out of favor as a diagnosis because local inflammation is likely not the primary driver of the condition.
This is not to say that inflammation can never be a contributing factor, but it likely doesn’t need to be the focus of management. This is important to know because most people associate inflammation with the need for complete rest, ice, and anti-inflammatory medication, which are not going to be the main recommendations in this video.
Since medial epicondylitis isn’t entirely accurate, the term epicondylalgia was introduced to replace epicondylitis. However, medial epicondylalgia just means that the medial epicondyle is painful, which isn’t very helpful.
We also shouldn’t call it “golfer’s elbow” because it doesn’t only occur in golfers. It’s common in workers who do repetitive movements or forceful activities with their arms, wrists, or hands on a regular basis, as well as other sporting populations (including tennis players). Descatha 2003, Shiri 2006, Wolf 2010, Walker-Bone 2012
So what should we call it?
Medial Elbow Tendinopathy
According to Scott et al in 2020, medial elbow tendinopathy is the preferred term for persistent tendon pain and loss of function related to mechanical loading of the medial elbow tendons. Mechanical loading refers to any movements or activities that load the medial elbow tendons, like working with your hands, lifting weights, and playing sports.
The diagnosis is typically given when someone’s pain is reproduced with pinpoint pressure to the tendons, stretching of the tendons, or loading of the tendons, such as with resisted wrist flexion, resisted pronation, or gripping.
Based on this information, medial elbow tendinopathy is generally considered a clinical diagnosis, meaning that imaging, such as x-rays and MRIs, are not indicated unless there is suspicion of something like a fracture. However, it is important to consider other diagnoses in this region as well, such as an injury to the ulnar collateral ligament or involvement of the ulnar nerve.
Why Did You Get Medial Elbow Tendinopathy?
The million-dollar question is, “Why did you get medial elbow tendinopathy?”
A simplified framework is that it’s thought to occur when the intensity, frequency, and volume of tendon loading, such as when working, lifting, playing sports, etc., exceeds your capacity to recover and adapt appropriately.
Oftentimes, it comes down to doing too much, too soon. For example, maybe you started a new job at a warehouse that requires a lot of gripping, lifting, and carrying. Or perhaps you wanted to try a new hobby, so you started rock climbing with a friend. In these examples, you likely loaded your medial elbow tendons more than what they’re used to.
In either case, the goal of rehab is to balance out this load-capacity equation. You want your capacity to be greater than or equal to the various loads you’re experiencing on a day-to-day and week-to-week basis.
The idea is that you’re finding a Goldilocks-level of load that is tolerable (not too much, not too little, but “just right”) and gradually progressing it over time.
Load Management & Activity Modifications (Recommended)
Based on this information, my first recommendation for rehab is to modify aggravating activities to reduce the load side of the equation.
If you’re a gym-goer who can’t tolerate your current training program, you need to temporarily scale back by doing less sets per day or throughout the entire week, reducing the amount of weight you’re lifting, or making other adjustments to your routine.
For example, if exercises that require significant grip strength or endurance are problematic, here are three easy modifications:
- Use lifting straps
- Choose a different exercise that trains the same muscle groups without placing any demand on your grip
- Change your forearm position
I might expect a supinated position to be more provocative, but it’s not always the case, so you can experiment with a supinated, pronated, or neutral forearm position depending on comfort. You can also try equipment or handles that provide you with more movement variability.
If supinated biceps curls are uncomfortable, try hammer curls.
Loading of the wrist flexors while the wrist is in extension can also be problematic during certain exercises, such as barbell front squats and back squats.
If you can’t get your wrists into a more neutral position for front squats, you can use lifting straps so no wrist extension is required. If you can’t get your wrists into a more neutral position for low bar back squats, you can take a wider grip or switch to high bar back squats.
In both cases, it might be helpful to work on your shoulder external rotation mobility if a lack of range of motion is forcing you to grip the bar a certain way.
If you’re a golfer, or any other athlete, reduce how often you play, the total time you play each session, or the intensity at which you play. This can actually be a good time to focus on your technique.
Compared to your legs, trunk, and shoulder, your elbow should only be handling a small fraction of the overall workload when you’re playing sports. Working with a coach might help you discover errors in your technique that are contributing to excessive loading of your elbow. This is true for tennis (forehand), golf (backswing), baseball (throwing), and any other sport that may be contributing to your symptoms.
I understand that modifying aggravating activities may be more challenging for some individuals than others. For example, if your job requires repetitive bending and twisting of your elbow and wrist, you might need to get creative if you work for yourself or request modified duty if you’re employed by someone else.
Most modifications are not meant to be permanent. Temporary changes can help minimize flare-ups and get you on the right track for long-term success.
Understanding & Monitoring Pain (Recommended)
Another fundamental component of rehab is understanding and monitoring pain. Ask yourself 2 questions:
- Is my pain tolerable during exercise? There’s not a universally acceptable answer. You get to decide what tolerable means.
- Is my pain better, worse, or the same the day after exercise? If you feel fine during and immediately after exercise, but you have a significant worsening of symptoms the next day, that’s an indication that you’re doing too much and need to back off a bit.
You can assess your next-day symptoms with your normal functional activities or use a specific assessment, such as squeezing a ball.
For example, you rate your pain on day 1 with squeezing a ball as a 2/10 pain. You then perform your exercise routine within tolerance, go about your day, and go to bed without any major issues. The next morning you squeeze the ball again, but this time you rate your pain as a 5/10. This means that even though your symptoms were tolerable during exercise, you might have done more than what you can currently recover from. You didn’t do any harm, but decreasing the volume or intensity of exercise would be recommended.
Also, you can replace the word exercise with physical activity, work, or anything else that affects your symptoms.
Exercise Overview
Before diving into the exercises, I want to point out that some people may get better just from monitoring their symptoms, appropriately modifying aggravating activities, and gradually resuming their normal activities over time.
If you do incorporate these exercises into your plan, make sure they complement the rest of your routine. For example, if you’re highly symptomatic from repetitive overload at work, throwing more load at your elbow may not be the answer, at least initially.
The goal of the exercises is to slowly increase the tolerance and capacity of your medial elbow tendons and muscles, as well the rest of your upper body if required.
Whether you decide to do 1, 2, or all 5 of the movements depends on your symptoms, goals, time availability, etc. Tailor the exercises, and all of this information, to suit your individual needs.
Wrist Flexion Strengthening (Recommended) & Wrist Extension Strengthening (Optional)
The first recommended exercise is resisted wrist flexion because wrist flexion is one of the primary actions of the medial elbow tendons.
If you’re also experiencing tennis elbow or just want to be a little more comprehensive, you can include wrist extension strengthening as well.
You can superset 2-3 sets of 8-15 repetitions of each exercise, 3 times per week.
Ideally, you’ll be seated with your forearm supported on a table, bench, or your thigh. You can use a dumbbell, a band with or without a handle, or whatever household objects you have laying around. If the full range of motion is uncomfortable, you can shorten the range of motion or just perform an isometric which involves a static hold for 30-45 seconds.
If you also want to incorporate finger flexion strengthening, you can let your fingers extend as your wrist moves into extension and then curl them back up as you go into wrist flexion.
Pronation Strengthening (Recommended) & Supination Strengthening (Optional)
The second recommended exercise involves pronation strengthening because pronation is also one of the primary actions of the medial elbow tendons. For simplicity, you’ll likely include supination strengthening as well.
For both, your elbow should be bent with your arm tucked by your side, forearm supported or unsupported, and you can be sitting or standing. Hold onto the end of a dumbbell, dowel, hammer, or another household object.
The closer you grab to the center of that object, the easier pronation and supination become. Make the movements harder by grabbing lower, using something that’s heavier, or adding resistance in the form of a cuff weight.
You can also use a band, but you’ll have to train each direction individually. Supination would be optional in that scenario.
Once again, aim for 2-3 sets of 8-15 repetitions, 3 times per week.
All of these exercises should be performed slowly within a tolerable range of motion.
Grip Strength & Endurance (Recommended)
The last recommended exercise is geared toward grip strength and endurance. There’s no shortage of options. If you want to keep it simple, you can periodically squeeze a lacrosse ball, tennis ball, towel, or one of those hand grippers throughout the day.
If you want to do gym-based movements, aim for 2-3 sets of farmer’s carries or suitcase carries with dumbbells or kettlebells. You can grab the wide portion of either, like the hex part of a dumbbell or the bottom of a small kettlebell, for a different challenge. You can also do plate pinches with a larger bumper plate or with 2 smaller plates held together.
Aim for 2-3 sets of 15-45 seconds of total work, 3 times per week.
If you’re struggling with grip strength in the gym or elsewhere, try to find a balance between getting stronger and working toward your goals while not overworking yourself. If you think about exercises that require grip strength on a continuum, weighted pull-ups and heavy deadlifts are on the far right side while a standing row with a light band will be further toward the left side.
Pick suitable exercise variations, manage your training frequency, intensity, and volume, and use lifting straps as needed while improving your grip strength over time and making progress in the gym.
Shoulder Strengthening (Optional)
The first group of optional exercises involves shoulder strengthening.
There are 2 possible reasons you might choose to perform these exercises:
- You play a sport that would benefit from improving your shoulder strength, such as golf, tennis, or baseball.
- You also experience shoulder stiffness, weakness, or discomfort. Research demonstrates an association between medial elbow tendinopathy and shoulder–related symptoms, so these exercises may help with both issues.
There are an infinite number of options, so here are 5 to choose from:
Option 1: Side Lying External Rotation – Place your top arm at your side with your elbow bent to 90° while holding a weight in your hand. Rotate your arm outward as far as you can while keeping your arm at your side. Lower back to your stomach and repeat.
Option 2: External Rotation with Elbow on Knee – Sit with your elbow supported on your knee and a weight in your hand. Slowly lower the weight, rotating your arm inward as far as possible without letting your shoulder roll forward. Then, rotate back to the starting position.
Option 3: Banded External Rotation – With your elbows bent to 90° and pinned at your side, think about pulling the band apart. If you’re using a loop band, you can put it around your wrists so you don’t have to worry about gripping it. If you’re using a ribbon band, you can rotate your arms straight out or think about creating a “W.”
If you want to progress these exercises, you can perform them in what’s known as a “90/90 position” while standing or lying on your stomach.
Option 4: Scaption – With thumbs pointing up, raise your arms to about shoulder height or slightly higher. You are not raising your arms directly to the side or in front of you, but an angle in between. You can use a band or dumbbells.
Option 5: Prone Angel Progression – If you have access to minimal equipment, you can lie on your stomach and progress from performing Prone A’s to Prone T’s to Prone Y’s to Prone Angels.
However, these exercises can also be performed with varying forms of resistance, such as bands, cables, and weights.
If you decide to incorporate these optional shoulder strengthening exercises, aim for 2-3 sets of 10-15 repetitions or 30-60 seconds of total work, 3 times per week.
Thoracic Mobility (Optional)
The second group of optional exercises involves thoracic mobility.
There are 3 possible reasons you might choose to perform these exercises:
- You want to use them as a way to break up repetitive tasks. I’ll provide options that require no equipment and can be done anywhere.
- You play a sport that would benefit from improving your thoracic mobility, such as golf, tennis, or baseball.
- You also experience neck and/or upper back stiffness and discomfort. Research demonstrates an association between medial elbow tendinopathy and neck-related symptoms, so these exercises may help with both issues.
Here are 4 options:
Option 1: Side Lying Thoracic Rotation – Lie on your side with your hips and knees bent, and head supported. Rotate your top shoulder and arm toward the floor behind you, or as far as you can comfortably go.
Option 2: Seated Thoracic Rotation – With your arms out in front of you, reach one hand toward the wall behind you, return to the starting position, and then repeat on the other side. You can also lean forward, grab the opposite knee, and reach up toward the ceiling.
Option 3: Half Kneeling Thoracic Rotation – Set up in half kneeling against a wall with your arms out in front of you. Rotate your shoulder and arm toward the wall behind you, or as far as you can comfortably go. You can make this more challenging by turning the movement into more of a windmill.
Option 4: Deep Lunge with Thoracic Rotation – Step back, place one hand on the floor, reach up toward the ceiling with the other hand, lower back down, repeat, and then switch sides.
If you decide to incorporate any of these optional thoracic mobility exercises, aim for 1-2 sets of 6-8 repetitions per side as part of your workout or periodically throughout your day.
Guidelines, Not Rules
I’ll put an example program together in the summary of this blog, but please understand that these are guidelines, not hard and fast rules. I can’t provide suggestions that will account for every person’s unique goals, preferences, and circumstances. Remember, find what works best for you.
Let me also quickly answer a few questions that I anticipate receiving:
1. Why didn’t I include stretching?
Any benefits from stretching should be achieved through the exercises I’ve given when performed slowly and through a full range of motion. You certainly can stretch if it feels good, doesn’t exacerbate symptoms, and doesn’t take away from the other exercises.
2. Why didn’t I discuss eccentric wrist flexion, which involves assistance from your other hand so you’re just doing the lowering portion of the exercise?
Eccentric exercises were traditionally believed to be the best approach for tendinopathies, but research over the years has shown that eccentric-only exercises aren’t necessary. I prefer an approach that achieves the same results in less time while being easier to track and progress.
3. Is there anything else you can do?
Yes! There is a growing body of literature, including research related to medial elbow tendinopathy, that tendinopathies are often associated with other lifestyle and metabolic factors, such as cardiovascular disease, diabetes, smoking, etc.
This is NOT to say that they are the cause of your symptoms or even a contributing factor, but if you’ve been meaning to positively influence your general health and well-being by changing your exercise, nutrition, and/or sleeping habits, this might be a good time to kickstart your journey.
One of the easiest methods for improving health is simply walking more. Something is always better than nothing, and short walks throughout the day can be a great way to help break up any repetitive tasks that you’re doing with your wrist or elbow.
Surgery, Injections, Adjunct Treatments
What about surgery, injections, and other adjunct treatments?
Research related to medial elbow tendinopathy is scarce compared to lateral elbow tendinopathy because it is much less common. However, since they are similar in nature, we can attempt to make inferences based on the research related to lateral elbow tendinopathy:
- Research consistently demonstrates that cortisone/corticosteroid injections may provide short-term benefits, but lead to worse outcomes in the medium and long-term for lateral elbow tendinopathy. Smidt 2002, Bisset 2006, Coombes 2013, Olaussen 2015, Coombes 2015, Vicenzino 2017, Karanasios 2021, Couple 2022
- Current research does not support the use of PRP injections for lateral elbow tendinopathy.
- Current research also suggests that surgery should not be performed for lateral elbow tendinopathy.
What about massage, icing, or whatever else you can think of? If it’s low cost and low risk, you can pretty much try out anything, including wearing an elbow strap or compression sleeve. However, these things aren’t meant to be a long-term solution and shouldn’t take away from the focus of a structured plan.
Summary
In summary, medial elbow tendinopathy is the preferred term for persistent tendon pain and loss of function related to mechanical loading of the medial elbow tendons. Mechanical loading refers to any movements or activities that load the medial elbow tendons, such as working with your hands, lifting weights, and playing sports.
We shouldn’t call it “golfer’s elbow” because it doesn’t only occur in golfers players. It’s common in workers who do repetitive movements or forceful activities with their arms, wrists, or hands on a regular basis, as well as other sporting populations (including tennis players).
Medial elbow tendinopathy is thought to occur when the intensity, frequency, and volume of loading exceeds your capacity to recover and adapt appropriately.
Therefore, the goal of rehab is pretty simple: it’s to initially reduce those loads to a tolerable amount and then make sure that your capacity is greater than or equal to the various loads you’re going to be experiencing on a day-to-day and week-to-week basis.
If you plan on incorporating exercise and just want to focus on the local function of the medial elbow tendons, these are three things you want to do:
1. Wrist flexion strengthening for 2-3 sets of 8-15 repetitions, 3 times per week. As an optional add-on, you can pair this with wrist extension strengthening.
2. Pronation and supination strengthening with a weight or household object for 2-3 sets of 8-15 repetitions, 3 times per week. If you’re using a band, strengthening of the supinators is optional.
3. Grip strength and endurance, aiming for 2-3 sets of 15-45 seconds of total work, 3 times per week.
If you also wanted to focus on your shoulder, neck, and thoracic spine because you play sports or have other symptoms associated with those areas, two optional exercise categories include shoulder strengthening and thoracic mobility.
The shoulder strengthening exercises can be performed for 2-3 sets of 10-15 repetitions or 30-60 seconds of total work, 3 times per week prior to the wrist and forearm exercises.
The thoracic mobility exercises can be performed for 1-2 sets of 6-8 repetitions per side as part of your workout or periodically throughout your day.
Since your overall health and well-being can have an affect on your medial elbow symptoms and function, taking steps to a healthier lifestyle can be a beneficial component of recovery.
You can incorporate adjunct treatments that alleviate pain, but they’re not the focus of rehab, especially if they’re high cost or high risk.
Regardless of what you decide to do, it’s important to tailor the plan to your individual goals and needs. There is no quick fix for medial elbow tendinopathy, so it’s helpful to set realistic expectations and plan for the process to take a minimum of 3 months.
Do you want a structured plan that’s going to provide you with the knowledge and tools to feel more confident, capable, and resilient than ever before?
Check out our Golfer’s Elbow Program!
Want to learn more? Check out some of our other similar blogs:
Tennis Elbow, Improving Elbow Range of Motion, Triceps Tendinopathy
Thanks for reading. Check out the video and please leave any questions or comments below.
