I’m presenting next week to my class and the subject is ‘Management of golfer’s elbow’. I understand that it’s a tendinopathy of the wrist flexor and pronator tendons and an increase in inflammation isn’t always present, therefore it’s sometimes called epicondylalgia and not epicondylitis. I believe the clinical presentation is usually pain around the medial elbow with resisted wrist flexion and pronation, pain with gripping, and tenderness around the medial epicondyle.
So I was hoping this would be a fairly straightforward subject but after doing a bit of digging there seems to be not much of a consensus regarding the treatment of golfer’s elbow (or tendinopathies in general!). For example, I’ve heard from Greg Lehman that upper limb tendinopathies seem to respond differently to pain-provoking exercise than lower limb tendinopathies. It seems that surgery doesn’t outperform sham surgery or exercise for the treatment of tendinopathy and should only be considered after 12 months of physical therapy. I’ve read a few papers and watched a few lectures from Jill Cook and Ebonie Rio. Isometric exercise appeared to be uniquely promising for short-term pain reduction, but a meta-analysis of relevant trials found no significant difference between isometric and isometric exercise for immediate pain reduction (although the direction of effect was in favor of isometric exercise). Is immediate pain reduction the thing we are most interested in anyway? Lastly, there doesn’t seem to be much evidence for golfer’s elbow specifically. I don’t know how comfortable I am extrapolating evidence from lower limb tendinopathy.
So when discussing treatment, I thought I’d start with MSK best practice guidelines and frameworks promoted by Peter O’Sullivan and others
So that will involve
A thorough subjective and objective assessment to screen for red flags and serious pathology
Asking patients about their goals, expectations, and asking what recovery looks like to them. Let patients tell their story.
Identifying and addressing psychosocial factors that may be contributing to their pain and function
Involving patients in decision making
Only request scans/imaging if you feel it is going to change management or if serious pathology is suspected
Only use manual therapy as an adjunctive treatment
Advice the continuation or resumption of work (make adaptations if necessary)
Address general health factors (sleep, physical activity, diet, etc)
Challenge unhelpful beliefs about pain and educate using an active-learning approach
Coach towards self-management
For a general rehab approach, I would suggest modifying current activities where possible to allow the patient to continue to carry out ADLs and physical activity without intolerable pain. I like Greg Lehman’s saying “calm shit down, build shit back up”. So if for example, someone is experiencing pain doing pull-ups with an underhand grip, it may help to change the grip, rep range, ROM, tempo, etc to reduce symptoms during exercise. The exercise can then be gradually progressed to the old version.
For a more specific approach (as I know the lecturer will want me to discuss specific exercises), Isometric wrist flexor exercises could be used as a starting point. Then once symptoms have calmed down a bit, more dynamic exercises can be used for the wrist flexor muscles.
I understand there’s not great evidence for steroid injections or any manual therapy modalities.
I just wanted to check that I’m on the right path or if there’s anything big that I’m missing. Any recommended reading would be great. I found the tendinopathy article very useful btw!
Nice work! It definitely sounds like you’ve done your homework so far.
You are right that there isn’t a ton of direct evidence that’s highly promising, and to some extent we end up having little choice but to extrapolate from other body areas, as if “a tendon is a tendon”.
I agree with your discussion on the general approach here, and how we would go about it.
For a general rehab approach, I would suggest modifying current activities where possible to allow the patient to continue to carry out ADLs and physical activity without intolerable pain. I like Greg Lehman’s saying “calm shit down, build shit back up”. So if for example, someone is experiencing pain doing pull-ups with an underhand grip, it may help to change the grip, rep range, ROM, tempo, etc to reduce symptoms during exercise. The exercise can then be gradually progressed to the old version.
Those are all good options, although the primary issue with pull-ups may be absolute loading, and switching to a lat pulldown (either prone or supine grip, with or without a tempo/pause etc.) can be a way to reduce the load to “sub-bodyweight” compared with chins.
For a more specific approach (as I know the lecturer will want me to discuss specific exercises), Isometric wrist flexor exercises could be used as a starting point. Then once symptoms have calmed down a bit, more dynamic exercises can be used for the wrist flexor muscles.
That is a reasonable starting point, although the evidence for isometrics is pretty mixed, with a wide inter-individual variation in symptom response to isometric loading. I would only use isometrics in someone for whom more “active” range of motion generated substantial spikes in symptoms. I’d probably start with some tempo-controlled wrist curls (especially tempo eccentric), and if those were intolerable even under very low loads, could try regressing further to isometrics.
I understand there’s not great evidence for steroid injections or any manual therapy modalities.
Agree that there’s no good evidence for manual therapy. And there’s evidence for harm from steroid injections in elbow tendinopathy.
I received two rounds of cortisone shots in my elbows prior to finding BBM’s content on tendinopathy. The first shot was into the tendon itself and the second shot went into the surrounding tissue near the tendon.
Do you think I permanently lowered my capacity to regain strength and function in the tendon as a result of this? That might explain why I’m still having difficulty rehabbing it after 3 years of focused physical therapy. Although I will say my symptoms ceased completely for a month a few months ago before returning, so maybe there is hope that I can completely get rid of it again, as long as I am more conservative with my training.
I really like the suggestion of switching to a lat pulldown if load is the aggravating factor, and also the idea that we don’t need to automatically regress to isometrics if eccentric and concentric work is tolerated. So a sensible approach could be:
Activity modification (changing something about the painful activity to reduce symptoms) > concentric + eccentric wrist flexion exercises > eccentric-only wrist flexion exercises > isometric wrist flexion exercises (at various muscle lengths depending on what is tolerated). If activity modification works, great. If not, move on to the next stage and so forth? But at the same time thinking about the big picture and treating the whole person, not just the tendon. And of course, if needing to regress right back to isometrics to “calm shit down”, we need to try to keep the other joints of the injured side moving to prevent disuse and deconditioning. So programming presses, rows, curls, etc (as long as they are tolerated) may be a good idea. Especially when “building shit back up”.
Do you think I permanently lowered my capacity to regain strength and function in the tendon as a result of this? That might explain why I’m still having difficulty rehabbing it after 3 years of focused physical therapy. Although I will say my symptoms ceased completely for a month a few months ago before returning, so maybe there is hope that I can completely get rid of it again, as long as I am more conservative with my training.
Unfortunately I have no way of knowing such a thing. However, your approach moving forward should be the same regardless of whether or not that is the case.