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View Full Version : Medial Epicondylitis - Rehab exercise advice, anyone?


Patrick Donnelly
08-16-2010, 02:14 PM
Bah. Sorry for the long post. Here's the short version: Golfer's elbow - what rehab exercises have you tried that have helped you fix it?

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Does anyone have some good suggestions for exercises to rehab medial epicondylitis (golfer's elbow)? I fell off a tightrope about a week and a half ago, landing pretty rough and messing up my right elbow. It wasn't anything awful through typical "daily life" ROM, but it got bad outside of that. It's improved substantially, but there are still remnants of it, primarily during:

- pronation of the forearm with the elbow locked out
- supporting a load with the elbow locked out (eg. a handstand)
- hyperextension of the wrist with the elbow fully flexed (eg. the rack position)

Since the injury, I've been doing a lot of:
- rice bucket work, only going to finger-depth, focusing on finger extension and pronation/supination of the hand, generally going for 2x5:00 on each hand (takes that long to feel any "burn")
- super-light forearm rollers (2kg)
- super light wrist-push-ups (cf. Coach Sommer's gymnastics stuff)
- some wrist stretching
- massaging the arm, from the wrist to the neck, with a golf ball
- icing, or more recently, alternately applying ice and heat
- taking fish oil (6g of EPA/DHA per day, but it's Costco's brand, which may be of dubious quality)
- unweighted forearm pronation/supination throughout the day (eg. when at a stoplight), for what probably totals a couple hundred "reps"


I had also been taking a good deal of ibuprofen (four of five 200mg per day), which I learned yesterday might be more of a hindrance than a help, so I cut that out. Also, I realized chins (unweighted) don't make for a good rehab exercise either, but I only did them on two days and won't be doing them again until I'm better.

Is there anything more or less I should be doing? Any advice from people "in the know" or who have experienced and successfully rehabbed a similarly severe case of golfer's elbow would be appreciated. This is a pretty huge impediment to my training, so I'd really like to see it gone.

Dave Van Skike
08-16-2010, 02:56 PM
take a look at slow loaded eccentrics.

http://www.youtube.com/watch?v=LtR8fYEUnXI

i've got some nasty Lateral Epicondylitis i'm battling rigth now. loaded eccentrics make it feel better, as does ART which I just started and 3 sessions in I'm way ahead.

Garrett Smith
08-16-2010, 05:54 PM
Look up Tyler Twist, or Reverse Tyler Twist (I forget which one is for which side of the elbow).

Allen Yeh
08-17-2010, 04:32 AM
Longer time off than you think you need is needed....as soon as my left elbow/arm was getting back up to 90% I'd do something stupid and reaggravate it and I was back almost from the beginning. It's only been years later that now it seems to finally be at 100% though I still feel a twinge or 2 here and there.

Patrick Donnelly
08-17-2010, 05:57 PM
take a look at slow loaded eccentrics.

http://www.youtube.com/watch?v=LtR8fYEUnXI

i've got some nasty Lateral Epicondylitis i'm battling rigth now. loaded eccentrics make it feel better, as does ART which I just started and 3 sessions in I'm way ahead.
Huh. That looks like a much better way to do wrist flexion in an isometric way than doing overhand forearm rollers eccentrically... I'll look into getting one of those flexbars if they're cheap, since I'm betting I'll probably f' up my elbows again in the future. Is there anything hand/wrist related they're good for?

In the meanwhile, it makes me think that doing an underhand forearm roller might let me do it a bit more effectively. I can't believe I hadn't thought of that before.


Longer time off than you think you need is needed....as soon as my left elbow/arm was getting back up to 90% I'd do something stupid and reaggravate it and I was back almost from the beginning. It's only been years later that now it seems to finally be at 100% though I still feel a twinge or 2 here and there.

Damn - what kind of injury did you sustain and how long did you give yourself to recover?

Allen Yeh
08-18-2010, 04:12 AM
Simliar to you but my left arm:

http://www.performancemenu.com/forum/showthread.php?t=2326&highlight=forearm

That was the thread I threw up back in 2008

The stupid things I did to reinjure myself after feeling better was:
Fall 2008 - Kipping pullups - curious how many...and hurt again.
Early Spring 2009 - pullups during an Army PT session

Like I said earlier it's better now but I still feel twinges when I do elbow rotations and nerve glides. Knowing what I know now I'd go back and do only hard Lower body stuff, ditch all upper stuff other than prehab type stuff.

Patrick Donnelly
08-18-2010, 07:22 AM
Allen, I dropped all the upper-body stuff (except rehab) as soon as I was injured. Unfortunately, I essentially dropped all lower-body stuff a few weeks ago (doesn't fit in with my goals), which leaves me with pretty much nothing to do right now. I can't even do ab work, since all of my favorites there involve the elbow (ab wheels, barbell windmills, hanging leg raises, human flags). It kind of sucks. I'm just doing a bunch of rehab work and flexibility stuff until this heals.

In the meanwhile, it makes me think that doing an underhand forearm roller might let me do it a bit more effectively. I can't believe I hadn't thought of that before.
Ok, wow, that wasn't helpful at all. Definitely made the joint feel stiff, ow. Strike that one off the list...




This injury gets me thinking that I probably ought to do start doing more dedicated grip work for hand/wrist/elbow prehab. Do you guys know of any good places to learn about the basics of how to train that stuff? I know there's GripBoard.com, but I've heard they're a bit fanatical over there and I'm not quite sure how much help is available there for beginners.

Allen Yeh
08-18-2010, 07:25 AM
Diesel Crew!

Steven Low
08-18-2010, 07:52 AM
Eccentrics are the way to go...

Patrick Donnelly
08-18-2010, 06:59 PM
Diesel Crew!
Right. I had forgotten about them. Thanks.

Eccentrics are the way to go...
Well, I've been doing eccentrics on the forearm roller - the concentric portion too, but really dragging out the eccentric - and they've been helping, but it's not a magical, instantaneous cure.

Steve Shafley
08-18-2010, 08:04 PM
I occasionally have issues with tennis elbow. An improvised graston/sastm type massage of the triceps and forearm with a pumpkin scraper and baby oil helps me. I'm going to warn you, the first few times you do this you bring up some kind of nasty bruises.

Google gua sha, graston, and sastm for more info. Gua sha is basically a folk chinese medicine technique.

Patrick Donnelly
08-19-2010, 03:30 PM
Shaf, that's an interesting alternative to the typical trigger point stuff. How hard are you supposed to push during the strokes and about how long do you normally go at it? Also, is there any particular reason you choose that method over just digging in with a golf ball?

Garrett Smith
08-19-2010, 06:12 PM
Gua sha is nothing like a golf ball.

You can do a version of it with those ceramic spoons and some oil/lotion.

Dave Van Skike
08-19-2010, 08:01 PM
pd, my t elbow has been going on for about 5 months. I've recently has super good luck with ART. if you can, try it out. I'm very pleased so far, still slow going but much better. liked it so much i set her to work on my perma-jacked shoulder.

Garrett Smith
08-19-2010, 08:30 PM
I hope eventually I can find a good ART person in my area. So far I haven't heard much good about the one guy I know who does it here.

Steve Shafley
08-20-2010, 05:27 AM
I go until I feel the knots let up (the pumpkin scraper actually provides a bit of sound that will go away when the tissue smooths) or until the blood comes to the surface, and it gets too painful.

I start light, and then get harder as I get a feel for how the tissue feels through the implement.

I do this in a few places, you may look like you've gotten beaten.

Lower quads: Usually doesn't bruise (when I say this, it's a visual bruise, you can usually feel the treated spots are a bit tender for a few days)
Traps: I have knots in my traps that have been there for years. Every time I do this kind of work on them, I have these huge bruises and the area swells up for a few hours. Those knots are going away.
Shoulders: Usually bruise
Pecs: Usually don't bruise
Biceps: Usually bruise
Triceps: Usually don't bruise visibly.

I would go easy until you get a feel for it. But, it's essentially free. Like Garrett said, the Chinese use smooth coins or those ceramic soup spoons. I've used smooth metal edges on spoons but settled on the pumpkin scraper as an implement that has a few different edge options.

This is all very much self-experimental. I read that Graston experimented on himself after a botched knee surgery (he was a surfer) when he developed his techniques, so....what the hell.

Steve Shafley
08-20-2010, 05:31 AM
On ART:

3 guys I know have torn their biceps tendons after being treated via ART for sore elbows and sore shoulders.

They speculate that the pain was diminished significantly but there was no real healing, and they hit things too hard too quickly and messed things up.

Garrett Smith
08-20-2010, 06:31 AM
On ART:

3 guys I know have torn their biceps tendons after being treated via ART for sore elbows and sore shoulders.

They speculate that the pain was diminished significantly but there was no real healing, and they hit things too hard too quickly and messed things up.
I hear the same thing often happens with cortisone shots to the shoulder for bicipital tendonitis...one month after the shot--SNAP!

In all actuality, the ortho who told my acquaintance this (the person did not tell me about this issue before it all went down) says that now they are doing PRE-EMPTIVE surgery, cutting the bicipital tendon to "relieve" the tendonitis.

Why would this be allowed to happen? My only guess is that people won't lay off long/well enough and that the conventional therapies for tendonitis just don't work that well.

Steven Low
08-20-2010, 08:53 AM
Well, here's what happens.

When you overwork or trauma injure something usually there's inflammation. But in the case of chronic tendonitis after a certain period there's no inflammation anymore and it becomes a chronic degenerative disease (hence tendinosis).

When this occurs, since some inflammation is necessary for healing process even when you decrease pain to the area it's still not healing.

That's what eccetrics or nitric oxide or prolotherapy, etc. are for. YOu get inflammation back into the area for the cases where there's chronic degenerative to stimulate healing process.

ART and other manual techniques obviously help decrease the pain because of overuse. Some of the overuse usualyl comes from gummed up and tight tissues in the elbow area constantly pulling/contracting on the tendon not allow it to heal properly.

So when you release that tension it feels better. But if the case is chronic it's not necessarily going to be healed. Hence, why you need eccentric exercises and stuff.

Cortisone does the same thing -- blocks the pain (or rather relieves it). Studies have shown it doesn't increase healing and that over 9-12 month periods result in no greater healing than placebos.

Dave Van Skike
08-20-2010, 09:25 AM
good information on the ART stuff but I don't think it should be a surprise that if you get a tendon injury and don't do the rehab...you could get a worse injury. it's not fair to indict ART, Cortisone or even NSAIDS for that. just a caution to get a running start when you return to your training.

and for gamy elbows..in addition to the eccentrics, doing your high reps curls and any extension work you can tolerate seems to be really important, before doing chins etc. i've seen several people come back from catastrophic elbow forearm injuries by including hundreds of band curls and press downs each day.

Garrett Smith
08-20-2010, 11:26 AM
Well, here's what happens.

When you overwork or trauma injure something usually there's inflammation. But in the case of chronic tendonitis after a certain period there's no inflammation anymore and it becomes a chronic degenerative disease (hence tendinosis).

When this occurs, since some inflammation is necessary for healing process even when you decrease pain to the area it's still not healing.

That's what eccetrics or nitric oxide or prolotherapy, etc. are for. YOu get inflammation back into the area for the cases where there's chronic degenerative to stimulate healing process.

ART and other manual techniques obviously help decrease the pain because of overuse. Some of the overuse usualyl comes from gummed up and tight tissues in the elbow area constantly pulling/contracting on the tendon not allow it to heal properly.

So when you release that tension it feels better. But if the case is chronic it's not necessarily going to be healed. Hence, why you need eccentric exercises and stuff.

Cortisone does the same thing -- blocks the pain (or rather relieves it). Studies have shown it doesn't increase healing and that over 9-12 month periods result in no greater healing than placebos.
My understanding of cortisone injections is that they relieve pain precisely because they are anti-inflammatory, not because of any anesthetic effect (which is why anesthetic is added to the shot, because the cortisone initially hurts like hell).

Cortisone shots plus exercise afterwards are bad news:
http://www.prolonews.com/knee_cortisone_prolotherapy_hauser.htm
Dr. Prem Gogia and associates at the Washington University School of Medicine in St. Louis, Missouri, did an excellent study bringing out the dangers of an athlete exercising after receiving a cortisone shot. They divided animals into three groups:

1. Group One: received a cortisone shot
2. Group Two: received a cortisone shot and exercised
3. Group Three: control group, received no treatment

This study was done in 1993 and was the first study to look at the effects of exercising after receiving a cortisone shot. The authors performed this study because it is common practice in sports medicine to give an athlete a cortisone shot for an acute or chronic injury. Athletes are typically returning to full-intensity sports activities within a few hours to one to two days after receiving the shot. The results of the study were unbelievable. The animals receiving the cortisone shots showed a decrease in chondrocytes, but when they received the cortisone shot and exercised, the chondrocyte cell count decreased by another 25 percent. Degenerated cartilage was seen in all of the cortisone-injected animals, but severe cartilage damage was seen in 67 percent of the animals that exercised and received cortisone. The cortisone and exercise group also showed a significant decline in glycosaminoglycan synthesis compared to the other groups. The authors concluded, ...the results suggest that running exercise in combination with intra-articular injections results in damage to the femoral articular cartilage.
Put simply, a corticosteroid injected tendon/ligament/cartilage will end up worse off structurally than it was before the injection, hence the tendon blowouts after corticosteroid injections.

You're likely right about the ART mechanism though.

Steven Low
08-20-2010, 07:23 PM
I didn't mean that was the actual mechanism of cortisone, haha. I know it's a very strong anti-inflammatory.

I do not think that's the mechanism of pain relief though... but maybe it is. I think it dulls it through the strong sympathetic response that occurs to it.

Garrett Smith
08-21-2010, 08:00 AM
Corticosteroid Injections of Joints and Soft Tissues (http://emedicine.medscape.com/article/325370-overview)
Actions of Corticosteroids

The mechanism of corticosteroid action includes a reduction of the inflammatory reaction by limiting the capillary dilatation and permeability of the vascular structures. These compounds restrict the accumulation of polymorphonuclear leukocytes and macrophages and reduce the release of vasoactive kinins.5 They also inhibit the release of destructive enzymes that attack the injury debris and destroy normal tissue indiscriminately.

Additionally, new research suggests that corticosteroids may inhibit the release of arachidonic acid from phospholipids, thereby reducing the formation of prostaglandins, which contribute to the inflammatory process. Finally, the clinician should appreciate the importance of introducing a needle into the injured area. The needle itself may provide drainage and a release of pressure, and it may also mechanically disrupt the scar tissue in the muscle.

Patrick Donnelly
08-21-2010, 10:32 AM
A lot of good information here. Thanks, guys.


The muscles in my forearms seemed to be nearly recovered, but now my tricep is giving me issues. I'm not sure if that's something new, or if I simply didn't notice it before because the other pain was so bad, but triceps stretching and eccentrics definitely help. Curls/chins are still an aggravator though, even when just using a 45lb bar.


Shaf, for knots/cramps in the traps there's one exercise I really like. Basically, do some bench dips (with the feet elevated too), but at the top of each rep, keep pushing your hands down and back until your hips come up as high as they can, then hold it for a moment or two. Don't stick the hips up using the glutes - really focus on driving the hands back. A few sets of these (3x15 or so) seems to do good things for the traps and rear delts. Facepulls are also good and you can do them well enough with rings/TRX if you don't have a cable machine.


Steve, if I'm still broken when practice starts again, I'm going to be counting on you to fix me.

Steven Low
08-23-2010, 01:18 PM
Ah prostaglandin reduction. So that may be the mechanism.