Medial Epicondylitis: Physical Therapy Exercises (Golfer’s Elbow)

Overview

Medial epicondylitis, commonly called golfer’s elbow, is a painful condition affecting the tendons that attach the forearm muscles to the inner side of the elbow. These muscles are involved in wrist flexion, forearm pronation, and gripping. Repetitive loading of these tissues can gradually exceed their ability to tolerate stress, resulting in pain and reduced function.

Despite the name, medial epicondylitis is not limited to golfers. It can affect people who perform repetitive gripping, lifting, throwing, tool use, racquet sports, weight training, or other activities that repeatedly load the wrist and forearm. The condition is generally considered a tendinopathy rather than simply an acute inflammatory process, particularly when symptoms have persisted for several weeks or longer.

Physical therapy focuses on reducing excessive tendon stress while progressively restoring the strength and load tolerance of the wrist and forearm muscles. A structured rehabilitation program may include activity modification, mobility exercises, progressive resistance training, and gradual return to work or sport. The American Academy of Orthopaedic Surgeons also recommends stretching and strengthening exercises as part of rehabilitation for medial and lateral epicondylitis.

Anatomy and Biomechanics

Medial epicondyle is the bony prominence on the inner side of the elbow. Several muscles responsible for wrist and finger flexion and forearm pronation originate through a shared tendon structure in this region.

The flexor-pronator muscle group helps control the wrist and hand during gripping and also contributes to stability of the elbow during activities that place valgus stress on the joint.

Medial epicondylitis usually develops when repeated loading of this muscle-tendon complex exceeds its current capacity. Examples include repeated gripping, forceful wrist flexion, forearm rotation, throwing, and lifting.

The condition may begin after a sudden increase in activity, but it can also develop gradually from repetitive occupational or sporting demands.

Pain is usually felt over or just below the inner elbow and may become more noticeable when the affected muscles are contracted against resistance.

Signs and Symptoms

The symptoms of medial epicondylitis can vary depending on the severity and duration of the condition.

Common symptoms include:

1. Pain or tenderness around the inner side of the elbow.
2. Pain during gripping or lifting.
3. Discomfort when bending the wrist against resistance.
4. Pain during forearm pronation.
5. Reduced grip strength because of pain.
6. Stiffness around the elbow or forearm.
7. Pain during repetitive work involving the hand and wrist.
8. Reduced tolerance for sports such as golf, throwing, tennis, or weight training.
9. Symptoms that increase after prolonged activity.
10. Difficulty performing everyday tasks such as opening jars, carrying bags, or using tools.

Some people experience symptoms primarily during activity, while others may notice aching after exercise or work.

Pain extending into the forearm can occur, but symptoms that involve significant numbness, tingling, or weakness in the hand require additional assessment because the ulnar nerve also passes close to the medial elbow.

Diagnosis

Clinical Assessment

Diagnosis is usually based on the history and physical examination.

The clinician will ask about the onset of symptoms, recent changes in exercise or workload, occupational activities, sports participation, previous elbow injuries, and movements that reproduce the pain.

The elbow, wrist, and forearm are then assessed for tenderness, range of motion, muscle strength, grip strength, and functional movement.

Resisted wrist flexion and forearm pronation may reproduce symptoms because these movements load the flexor-pronator muscle group.

The clinician may also assess the cervical spine, shoulder, wrist, and neurological function when symptoms do not fit a straightforward tendon presentation.

A thorough assessment is important because pain on the inner side of the elbow can have several possible causes, including ulnar nerve irritation, ligament injury, joint pathology, or referred pain.

Medical Testing

Imaging is not routinely required for every case of medial epicondylitis.

Ultrasound may be used to examine the tendon and surrounding structures, while MRI can provide more detailed information when the diagnosis is uncertain or a significant tendon, ligament, cartilage, or joint problem is suspected.

Electrodiagnostic testing may be considered when symptoms suggest ulnar neuropathy or another nerve-related condition.

Imaging findings should be interpreted together with the clinical examination because structural tendon changes do not necessarily correspond directly with the severity of pain or functional limitation.

Complications and Risk Factors

Most people with medial epicondylitis can improve with appropriate conservative management. Problems are more likely when the tendon continues to receive high repetitive loads without sufficient recovery or when rehabilitation is stopped as soon as pain begins to improve.

Modifiable Risk Factors

Factors that may increase the likelihood of medial elbow tendon pain include:

1. Repetitive gripping.
2. Frequent forceful wrist flexion.
3. Repetitive forearm rotation.
4. Sudden increases in training volume.
5. Heavy lifting without adequate progression.
6. Repetitive occupational tasks involving tools or manual work.
7. Poor recovery between demanding activities.
8. Returning to sport too quickly after a period of inactivity.
9. Inadequate forearm strength and endurance.
10. Continuing aggravating activity despite progressively worsening symptoms.

The exact contribution of individual risk factors varies between people. In many cases, the most important issue is a mismatch between the load being placed on the tendon and its current capacity.

Non-Modifiable Risk Factors

Previous elbow problems, age-related changes in tendon tissue, individual anatomical characteristics, and occupational or sporting demands may influence the risk of developing medial elbow tendinopathy.

Having a previous episode does not mean that recurrence is inevitable. Appropriate strengthening and gradual exposure to occupational or sporting loads can help improve the tendon’s capacity.

Red Flags

Seek medical assessment if you experience:

1. Sudden severe pain following a forceful injury.
2. A popping sensation followed by substantial weakness.
3. Significant swelling or bruising after trauma.
4. Loss of normal elbow movement.
5. Persistent numbness or tingling in the ring and little fingers.
6. Progressive weakness of the hand.
7. Repeated elbow instability.
8. Severe pain that does not correspond with activity.
9. Fever, marked redness, or warmth around the elbow.
10. Symptoms that continue to worsen despite appropriate activity modification.

These findings may indicate a condition other than uncomplicated medial epicondylitis and may require additional medical investigation.

Physical Therapy Exercises

Exercise is a central part of rehabilitation for medial epicondylitis. However, the exercise program should progress according to pain, strength, irritability, and functional requirements rather than following a rigid routine.

The evidence specifically studying exercise for medial epicondylitis is more limited than the evidence available for lateral epicondylitis. A recent systematic review found that eccentric exercise may improve pain and function, but the studies were small and heterogeneous, so the certainty of evidence remains low.

1. Wrist Flexor Stretch

Sit with the affected arm straight in front of you and the palm facing upward. With the opposite hand, gently pull the fingers and wrist backward until you feel a mild stretch along the inner forearm.

Hold for 20 to 30 seconds and repeat 2 to 4 times.

The stretch should feel mild rather than painful. Avoid forcing the wrist into a large range, particularly when the tendon is highly irritable.

Stretching may be useful for restoring comfortable forearm mobility, but it should normally be combined with progressive strengthening rather than used as the sole treatment.

2. Isometric Wrist Flexion

Sit with the affected forearm supported on a table and the palm facing upward. Use your opposite hand or a stable surface to resist the injured hand while you gently attempt to bend the wrist upward without allowing visible movement.

Hold the contraction for approximately 20 to 30 seconds and repeat 4 to 5 times.

Start with a level of resistance that does not substantially increase symptoms.

Isometric loading can provide an accessible starting point when dynamic strengthening is uncomfortable. As symptoms settle, progress toward controlled movement against resistance.

3. Eccentric Wrist Flexion

Sit with your forearm supported on a table and the palm facing upward, allowing the wrist to extend slightly beyond the edge. Hold a light dumbbell in the affected hand.

Use the opposite hand to help lift the wrist into flexion. Then slowly lower the weight over approximately 3 seconds.

Begin with 1 to 2 sets of 10 repetitions.

Progress the resistance gradually as the exercise becomes easier to tolerate.

The AAOS therapeutic exercise program specifically includes progressive wrist-flexion strengthening and describes an early stage in which the lowering phase is emphasized before progressing to the complete movement.

4. Resisted Forearm Pronation

Sit with the elbow supported at approximately 90 degrees. Hold a light resistance band or a suitable handle with the palm facing upward.

Slowly rotate the forearm so the palm moves downward, then return to the starting position in a controlled manner.

Perform 2 sets of 10 to 15 repetitions.

Keep the elbow close to your body and avoid compensating with shoulder movement.

This exercise targets the forearm muscles involved in pronation and can be introduced once basic wrist loading is tolerated.

5. Grip Strengthening

Hold a soft therapy ball or suitable grip device in the affected hand. Squeeze gradually rather than suddenly, hold the contraction for a few seconds, and then relax.

Begin with 2 sets of 10 repetitions.

As strength improves, gradually increase resistance or holding time.

Grip exercises should not produce significant medial elbow pain. If squeezing strongly reproduces symptoms, reduce the resistance and build capacity more gradually.

6. Progressive Wrist Strengthening

Once basic exercises are well tolerated, increase resistance using a dumbbell, resistance band, or other appropriate equipment.

Perform 2 to 3 sets of approximately 8 to 12 repetitions with controlled movement.

The goal is to progressively improve the strength and endurance of the flexor-pronator muscle group.

The AAOS program recommends gradually increasing resistance and progressing through different exercise stages rather than immediately using heavy loads.

7. Functional Loading and Return to Activity

• The final stage of rehabilitation should reproduce the activities that originally caused symptoms.
• For a golfer, this may include progressive gripping, wrist control, and eventually practice swings before returning to full play.
• For a manual worker, rehabilitation may progress toward lifting, carrying, gripping tools, and repetitive work tasks.
• For an athlete, exercises may progress toward throwing, racquet movements, weight training, or other sport-specific activities.
• The progression should be gradual, with adequate recovery between higher-load sessions.

Medical Treatment

• The first step is usually to modify activities that repeatedly aggravate the tendon while maintaining comfortable movement and general physical activity.
• Complete rest for a prolonged period is generally not the goal. Tendons need an appropriate level of mechanical loading to regain capacity.
• A physical therapist may use manual therapy, exercise, education, activity modification, and other adjunctive treatments according to the individual's presentation. Evidence for exercise and mobilization in epicondylitis is stronger for lateral than medial epicondylitis, so treatment should not simply assume that findings from tennis elbow research apply equally to golfer's elbow.
• Pain-relieving medication may be considered by a physician when appropriate. Medication choices should take into account the person's medical history and potential contraindications.
• Bracing or a counterforce strap may be considered for selected patients to temporarily modify loading during aggravating activities, although it should not replace progressive rehabilitation.
• Injections are sometimes considered when symptoms persist, but they should be discussed carefully with an appropriate clinician because short-term symptom relief does not necessarily mean improved long-term tendon capacity.

Surgery is rarely the first treatment for medial epicondylitis. It may be considered in selected patients with persistent symptoms and significant functional limitation after an adequate course of well-supervised conservative treatment, or when another structural problem requires surgical management.

Finding a Physical Therapist

A physical therapist can determine whether the symptoms are consistent with medial epicondylitis and identify the specific activities that are placing excessive stress on the elbow and forearm.

A complete rehabilitation program should address more than the painful area. It may include wrist and forearm strength, grip capacity, shoulder and upper-limb mechanics, work technique, sport-specific demands, and gradual exposure to the activities the patient needs to perform.

For people who work with their hands or participate in sports, the final rehabilitation stages should reproduce real-world demands rather than stopping once everyday pain has decreased.

If you are looking for a physical therapist for an assessment and individualized rehabilitation plan, you can browse available professionals through HealthandPhysio's Physical Therapist Directory.

The goal of rehabilitation is not simply to reduce elbow pain. It is to restore the tendon’s ability to tolerate the gripping, lifting, throwing, working, or sporting demands that matter to the individual.

Medical Disclaimer

This article provides general educational information and does not replace an individual assessment by a qualified healthcare professional. Pain around the inner elbow can have several causes, and the appropriate treatment depends on the diagnosis, severity, duration of symptoms, and individual health factors. If you develop sudden weakness, significant swelling, neurological symptoms, or severe pain following an injury, seek medical evaluation.