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Golfer’s elbow is also known as medial epicondylitis and is the less common sister condition of tennis elbow, both conditions sharing the tendon degenerative nature without inflammation. They are referred to as tendinopathies due to the pathological changes which occur inside the tendon without an inflammatory process. Not just occurring in golfers, golfer’s elbow also appears in racquet sports, cricket bowling, weightlifting and archery.

The forearm muscles, which flex and rotate the forearm, originate in tendon-like tissue at the medial epicondyle, the bony lump on the inside part of the elbow. Due to the lack of inflammation the term tendonitis is not correct and tendinopathy, an internal process of degeneration, is the preferred term. Any activity which pushes the lower arm outwards away from the body, into so-called valgus or “knock elbow”, puts extra force on the muscles of the flexor origin which are resisting the movement.

High stresses occur in the cocking phase of a throw and during the subsequent acceleration, and in the golf swing from high backswing down to near the ball strike. Golfers are more likely to have their dominant hand affected and tennis players who use heavy topspin in their forehands are also more at risk.

Tennis elbow is more common but golfer’s elbow remains the most reported pain problem over the inner elbow. Men are more likely to be sufferers than women in a 2:1 proportion, with most people affected in their early adult or middle years. The dominant hand is typically affected in two-thirds of cases, a third report a sudden pain onset with pain coming on slowly over time in the rest.

Patients complain of aching pain over the front of the inner epicondyle, worse with repeated wrist flexion and better with rest. Pain can occur in the shoulder, elbow, forearm or hand, with weakness in the lower arm and hand also. The physiotherapist will examine the bony areas and joints of the elbow, check the muscles and their tendinous insertions. The physio palpates the ulnar nerve in the groove behind the elbow, called the “funny bone” when it’s hit. The nerve can give pins and needles or weakness in the forearm and a neurological examination excludes other causes of pain or weakness.

Most golfer’s elbow treatment is conservative, not surgical. Treatment involves activity modification, forearm or wrist splinting, anti-inflammatory drugs, steroid injections and physiotherapy. Modification of the use of the arm is vital to prevent ongoing stimulation of the condition, so altering the mechanics of swinging the golf club or other sporting equipment is essential. Patient education continues with the identification of aggravating activities and postures and the patient is taught to avoid them.

Non-steroidal anti-inflammatory drugs are used by physios in the initial acute phase to reduce pain and inflammation along with avoiding painful movements, use of ice, gentle stretches, friction massage and ultrasound. As the problem settles and becomes sub acute the aims change to improving flexibility by stretching, increasing strength and normal activities. A forearm brace may also be used or a wrist brace to rest the wrist muscles. Once the problem is chronic the programme continues with reduced use of the splint and re-introduction of sporting activities.

Doctors inject corticosteroid medication into the sites of chronic golfer’s elbow but this treatment appears to be more useful in the earlier, acute cases. Other therapies, such as shockwave or laser, have been used but do not seem to be effective. Once physio has been attempted for some time without improvement then a surgical approach may be considered, cutting out the abnormal tissue from the tendon. The ulnar nerve can be transposed around to the front of the joint from its position in the groove posteriorly.

Correction of sporting technique, such as the golf swing, is best achieved by engaging a professional instructor who can also advise on stretches, fitness work and muscle strengthening. Athletes should warm up well before sport and stretch effectively afterwards, choosing good technique and selection of appropriate equipment. Doctors and physiotherapists may need to monitor patients, especially athletes, very carefully as they tend to continue to perform through the pain.

Injuring the knee is one of the most common general and sporting injuries and can give long-term problems with pain, stability and functional activities. Physios begin with the subjective examination, asking about the cause of the injury, the amount of force involved, whether the knee swelled up quickly or the knee was unstable afterwards and the person found it difficult to weight bear.

The amount of pain a patient suffers indicates the severity of the injury involved and the particular location of the pain can point to which anatomical structures have been injured. As the knee will be very difficult to walk on in the presence of a fracture these injuries are rarely missed in diagnosis. During the examination the physiotherapist will test the knee structures to look for the cause of the injury.

The Knee Examination

The physiotherapist will look at the knee and check for effusion by observation or doing the patellar tap test. The knee can swell greatly and be very tight, needing aspiration by a needle. How well the knee can move when not weight bearing is assessed by the physio. Knee extension is the movement of straightening the knee out and flexion is bending the knee. The knee does have a certain degree of rotation but that is rarely checked in the initial period.

The reaction to examination testing indicates how the treatment plan should proceed. The pain level, ease of joint movement and reaction to tests are included in this assessment. The patient moves the joint actively with the physiotherapist adding passive movement to test the joint further. The power of the main antigravity muscles, the hamstrings and quadriceps, are tested by manually resisting the knee movements or asking the patient to perform weight bearing movements.

The medial and lateral collateral ligaments of the knee give side to side stability to the joint, and the anterior cruciate ligament and posterior cruciate ligament provide front to back stability. Provided pain is not severe the physiotherapist will test these ligaments manually, pushing the knee into knock-knee and bow-leg for sideways stability and the forward and backward movement of the shin bone to assess cruciate function. The physio will palpate round the joint manually to search for clues to injured structures.

Physiotherapy treatment plan

An acutely painful knee is treated using the PRICE technique, starting with protection of the joint if necessary by using a brace to stabilise it. Crutches or sticks can be used to reduce weight bearing on the knee and allow a good walking pattern. Ice treatment, or cryotherapy, is a first line treatment for an acute knee, reducing pain and the swelling which permits increased movement and progression of treatment. A neoprene knee sleeve may be worn to squeeze the swelling and increase stability.

A reduction in swelling and pain allows the physiotherapist to give exercises to improve the knee’s ranges of movement and strength. The largest and most powerful muscles are the quadriceps and the hamstrings. The quadriceps allows knee power for getting up from sitting, going up and down stairs and walking, keeping the knee stable. After the knee copes with exercise on the plinth the physio will move to exercises in weight-bearing and in more active activities.

A normal knee joint involved in activity sends a stream of impulses up to the brain, informing us of the joint position at all times, the degree of muscle activity and movement. This is known as joint position sense (JPS) or proprioception, which is lost to some degree after injury and restoring it to a normal level is vital if the knee is to successfully return to activity. The physio starts with balancing on one leg and progresses to standing on a wobble board and finally works on active, dynamic exercises in preparation for sport.