Alternative Approach to Golfer's Elbow Rehab

[Limie]

What should be the goal of the rehab exercises?


I'm following the recommendations in the tendinitis article to address some pain around the medial epicondyle on my right elbow. The exercise I've been doing is a bench supported wrist flexion, but after about 5 sessions this is no longer eliciting any sensation in the sore spot during the exercise despite no overall improvement in my symptoms (only the second week of rehab). I have found a variation of that triggers that spot a lot more - isometrically resisting my wrist going into extension as I extend and flex at the elbow.

Does this difference in pain replication indicate my variation is a better choice for my rehab, or am I getting too caught up in chasing the pain?

[Hannah Mora]

Honestly, I think you might be getting too caught up in chasing the pain. As you know from reading the article on tendinopathy, these things take time. I would not expect a huge reduction in symptoms after only 2 weeks of rehab. For tendon issues, we are thinking more in the realm of several months for tissue restructuring. Not a sexy answer, but I think you should keep doing what you're doing.

If you aren't already, focus on heavy slow wrist flexion with a tempo (3 second concentric, no pause, 3 second eccentric) and chose a weight that is heavy (RPE 7-8) for 3-4 sets of 6-10 reps (start with 10 reps and gradually work down to 6 week by week). I would do this 3-4 times/week.

Hope this helps!

Hannah

[Abrar]

Hello Dr Mora.

Where can we read in-depth about tissue restructuring of tendons?

[Derek Miles]

This is more of a textbook level question as there is ongoing debate regarding what is the rate of tendon turnover, the relationship between tendinopathic changes and symptoms, and what constitutes normal/healing/ideals. What Dr. Mora is referencing is based from the articles by Kongsgaard and Beyer. While prescriptive this likely is not a strict protocol which is why there is some variation in set/rep scheme in what is often recommended. However, the shortest protocol you will likely encounter is 12 weeks (see papers above). In terms of tendon turnover, there is ongoing debate about the rate but tendons are often referred to as "mostly dead during life" due to the low cellular composition and high percentage of extracellular matrix. You can reference Xu here. There is another paper by Heinemeir that could make the argument tendons don't really turnover beyond adolescence. This obviously is countered in the Kongsgaard papers to some degree but then it becomes a conversation of "how much" and how much is contingent upon the loading protocol. For a while you would hear conversations about "treating the donut not the hole" but I would argue that stance is far from settled and even some of the vernacular being used around that time may have been misplaced. This is a complex topic that is far from settled in the evidence. If you want to learn more I would start there but I fully agree with Dr. Mora's advice.

[Abrar]

Thank you for the informative post and references, Dr Miles. I appreciate it a lot.

[Limie]

Honestly, I think you might be getting too caught up in chasing the pain. As you know from reading the article on tendinopathy, these things take time. I would not expect a huge reduction in symptoms after only 2 weeks of rehab. For tendon issues, we are thinking more in the realm of several months for tissue restructuring. Not a sexy answer, but I think you should keep doing what you're doing.

If you aren't already, focus on heavy slow wrist flexion with a tempo (3 second concentric, no pause, 3 second eccentric) and chose a weight that is heavy (RPE 7-8) for 3-4 sets of 6-10 reps (start with 10 reps and gradually work down to 6 week by week). I would do this 3-4 times/week.

Hope this helps!

Hannah

Thanks for the response, but it is possible I did not make myself clear in my OP.

It is because I appreciate that this is going to take a while to resolve that I have been surprised at how quickly the specific rehab exercise I have been doing has stopped eliciting any pain or discomfort when performing them. The first week or so went as expected, but by the 5th or 6th session I could perform the exercises with no pain or discomfort, despite the elbow otherwise still being really sore. This has left me wondering whether the exercise is the right choice (standard bench supported DB wrist flexion) for what Im experiencing, and whether I'd be better served by trying variations that produce the expected level of discomfort.

Essentially can the rehab still work if the exercise you're doing is completely pain free?

[fbc91]

Have you increased the load any?

[Limie]

Have you increased the load any?

I have. Initially based on pain tolerance, but more recently based purely on strength/performance capacity. Even with increased load the reps themselves are not painful, yet often getting out of position at the end of the set is uncomfortable (isometric hold of the wrist with a long lever arm with the elbow relatively fully extended).

[fbc91]

I have. Initially based on pain tolerance, but more recently based purely on strength/performance capacity. Even with increased load the reps themselves are not painful, yet often getting out of position at the end of the set is uncomfortable (isometric hold of the wrist with a long lever arm with the elbow relatively fully extended).

You could move on to curls, rows, and/or pulldowns. That's what I did after a few months.