Medial Epicondylalgia (Golfer’s Elbow): Overview and Evidence Summary

Condition Overview

Medial epicondylalgia—commonly known as golfer’s elbow—is a tendinopathy affecting the flexor–pronator muscle group where it attaches to the medial epicondyle of the humerus. Although the name implies a sporting origin, most cases arise from repetitive occupational or daily-life strain rather than golf. In fact, many individuals who develop this condition have never stepped onto a golf course. Instead, they tend to be manual workers, tradespeople, carpenters, gardeners, weightlifters, racquet sport athletes, or office workers who spend long hours gripping, typing, or performing repetitive wrist and forearm tasks.

The flexor–pronator mass—including pronator teres, flexor carpi radialis, palmaris longus, and flexor carpi ulnaris—acts as a dynamic stabilizer of the medial elbow. When repetitive gripping, pulling, wrist flexion, or forearm pronation exceed the tendon’s capacity, microscopic changes accumulate within the tendon. Over time, this leads to disorganization of collagen fibers, increased tendon thickness, localized tenderness, and pain when performing activities that require resisted wrist flexion or forearm pronation.

Patients typically report a gradual onset of pain along the inner elbow, sometimes with referral down the medial forearm. Activities such as gripping a suitcase handle, pouring a drink, lifting a heavy bag, or using a screwdriver can provoke symptoms. Manual workers may notice discomfort toward the end of their workday, while athletes may feel the elbow “give way” during powerful swings or throws. Typists or computer users may experience subtle but persistent discomfort that worsens with prolonged use of a mouse or keyboard.

In more longstanding cases, patients describe aching at rest, stiffness in the morning, or difficulty maintaining grip strength during sustained activity. Rarely, there may be irritation of the ulnar nerve due to its close anatomical relationship with the medial epicondyle, leading to tingling or numbness in the forearm or hand.

Similar to lateral epicondylalgia, medial epicondylalgia responds best to progressive loading, combined with manual therapy, ergonomic modification, and patient education. However, it’s often slower to resolve than its lateral counterpart due to the complex, multi-directional demands placed on the flexor–pronator mass.

Summary of Current Evidence for Medial Epicondylalgia

Evidence-Based Management Discussion

Biomechanical Demands on the Flexor–Pronator Tendon

The flexor–pronator tendon complex stabilizes the medial elbow during gripping, lifting, throwing, and rotational tasks. These muscles must coordinate intricate load-sharing where twisting, pushing, and pulling converge. Because of this, the tendon is exposed to large cumulative loads even during seemingly simple tasks—typing, gripping a steering wheel, carrying shopping bags, gardening tools, weight lifting, or DIY projects.

Medial epicondylalgia often emerges when:

• A repetitive task is performed more frequently or more forcefully

• Training volume increases abruptly, especially in athletes

• Grip technique is inefficient (e.g., excessively tight grip)

• Wrist flexion or pronation is performed under fatigue

• Work ergonomics place the forearm in sustained tension

Over time, microtrauma accumulates faster than the tendon can repair, resulting in the hallmark degenerative changes seen in tendinopathy.

Clinical Presentation and Functional Limitations

Patients usually describe a deep, localized ache at the inside of the elbow, which can intensify during gripping or lifting. Pain may radiate down the forearm toward the wrist. Activities that commonly aggravate symptoms include:

• Turning a key or screwdriver

• Lifting objects with the palm up

• Typing or using a computer mouse

• Performing curls, pull-ups, or rowing exercises

• Throwing sports such as cricket or baseball

Grip strength is often diminished, particularly when the elbow is extended. Palpation over the medial epicondyle reproduces pain, and resisted wrist flexion or pronation is typically provocative.

In some cases, the ulnar nerve—located in the cubital tunnel just behind the medial epicondyle—may become irritated, producing tingling in the ring and little fingers. This is not tendinopathy itself but a concurrent issue therapists must recognize.

Exercise Therapy: Progressive Loading as Core Treatment

Evidence consistently supports progressive tendon loading as the most effective long-term treatment for medial epicondylalgia. The tendon must gradually relearn how to tolerate load, rebuild strength, and regain function.

Phase 1: Establishing Tolerance and Reducing Irritability

Common early goals include:

• Reducing exposure to high-load gripping or pronation

• Introducing isometric wrist flexion to modulate pain and maintain tendon engagement

• Using pain as a guide rather than avoiding all discomfort—controlled load is key

• Gentle mobility exercises for the elbow, wrist, and shoulder

Isometrics may reduce pain and create a “window of opportunity” for more meaningful exercises.

Phase 2: Building Strength Through Controlled Loading

After the tendon becomes less reactive, strengthening progresses into slow, deliberate movements:

• Eccentric wrist flexion exercises with dumbbells or resistance bands

• Concentric–eccentric wrist flexion under controlled tempo

• Supination and pronation strengthening—important for restoring load-sharing

• Grip strengthening using putty, hand grippers, or rolled towels

• Functional loading such as controlled lifting tasks

Tendon loading must be progressed gradually—load, frequency, and speed adjusted according to symptom behavior.

Phase 3: Functional Integration and Return to Sport or Work

Late-stage rehab bridges the gap between strengthening and real-life demands:

• Sport-specific drills (e.g., golf swing mechanics, throw progression)

• Work-specific tasks (carrying loads, repetitive tool use, machinery handling)

• Plyometric or power drills for athletes (med ball throws, rapid gripping tasks)

In this phase, therapists emphasize control and quality of movement, ensuring that compensatory patterns do not persist.

Manual Therapy: Supporting the Loading Process

Manual therapy is valuable in reducing pain, improving mobility, and facilitating access to exercise:

• Soft tissue mobilization to wrist flexors/pronators

• Mobilization of the medial elbow joint to reduce discomfort

• Neural mobilization when ulnar nerve irritation coexists

• Thoracic and cervical mobilization when upper limb mechanics are affected

Manual therapy is not curative but enhances function and patient comfort, accelerating progress through the exercise program.

Ergonomic and Activity Modification

Ergonomics often determine whether the tendon continues to be overloaded. Therapists should assess:

• Keyboard and mouse positioning

• Grip size on tools or sports equipment

• Wrist position during repetitive tasks

• Workload distribution between hands

• Lifting technique—keeping wrists neutral reduces tendon stress

Small ergonomic improvements can make significant differences in symptom control.

Pharmacological Options and Injection Therapies

NSAIDs may reduce acute irritability, but they have limited impact on long-term tendon adaptation.

Corticosteroid injections can provide short-term relief but carry risks:

• Higher recurrence rates

• Potential reduction in tendon strength

• Masking pain, which leads to premature return to high load

PRP and other biologics show mixed outcomes; they may assist in stubborn chronic cases but should not replace progressive loading.

Surgical Management

Surgery is considered only when:

• Symptoms persist beyond 9–12 months despite excellent rehabilitation

• There is structural tendon tearing

• Symptoms significantly impair work or athletic participation

Procedures typically involve debridement of degenerative tissue and stimulation of tendon healing. Recovery still requires structured exercise postoperatively.

Clinical Considerations for Therapists

Therapists must take a strategic approach:

• Educate patients on the tendon healing continuum

• Present loading as the core treatment, not rest

• Guide progressions slowly and deliberately

• Address contributing factors from the shoulder girdle to the hand

• Monitor for signs of nerve involvement

• Reinforce that recovery is expected—but not instantaneous

Patients who understand why recovery takes time are far more likely to adhere to the program and achieve full resolution.

References

Tyler, T., et al. “Medial Epicondylalgia: Pathophysiology, Diagnosis, and Treatment.” American Journal of Sports Medicine.

Nirschl, R., et al. “Tendinopathy of the Elbow: Clinical Aspects and Management.” Journal of Bone and Joint Surgery.

Coombes, B., et al. “Tendon Loading Principles for Upper Limb Tendinopathies.” British Journal of Sports Medicine.

Bisset, L., et al. “Exercise and Manual Therapy for Epicondylalgia.” Journal of Physiotherapy.

Walz, D., et al. “Ultrasound and MRI Evaluation of Medial Elbow Pain.” Radiologic Clinics of North America.

Disclaimer

The information in this article is intended for educational purposes and is designed for qualified massage therapists, manual therapists, and rehabilitation professionals. It is not a substitute for medical advice, diagnosis, or treatment. Practitioners must work within their legal scope of practice and regional regulations. Hands-on techniques should only be performed by appropriately trained and licensed individuals. Niel Asher Education is not responsible for any injury, loss, or damage resulting from the use of this content.