Overview
Medial epicondylalgia, or golfer’s elbow, is a less common but equally disabling condition compared to lateral epicondylalgia. It involves degenerative changes at the common flexor tendon origin, especially in the flexor carpi radialis and pronator teres.
Evidence increasingly supports physiotherapy—including eccentric loading, manual therapy, and neuromuscular retraining—as a first-line intervention that can reduce pain, restore function, and lower recurrence rates without the need for corticosteroids or surgery.
Pathophysiology
Unlike inflammatory tendinitis, medial epicondylalgia is a tendinosis involving collagen disorganization, neovascularization, and microtearing from overuse. This leads to impaired load tolerance and grip strength deficits.
Evidence-Based Physiotherapy Interventions
1. Eccentric Loading Protocols
Tyler et al. (2014) conducted an RCT demonstrating that eccentric loading for the wrist flexors improved function and pain scores in medial epicondylalgia patients more than rest or conventional care.
Eccentric exercise promotes collagen synthesis and tendon remodeling, essential for long-term healing.
2. Manual Therapy + Exercise Combination
Seo et al. (2013) found that combining exercise therapy with manual techniques such as cross-friction massage and mobilizations provided superior outcomes over exercise alone in both medial and lateral epicondylalgia patients.
3. Neuromuscular and Postural Control
Although data is more robust for lateral elbow conditions, several case series and comparative trials suggest addressing proximal deficits (e.g., scapular dyskinesis or weak shoulder girdle muscles) may improve outcomes in chronic medial elbow pain.
Our Physiotherapy Approach Includes
- Progressive eccentric/concentric loading for wrist flexors
- Isometrics for early-stage pain relief
- Scapular and shoulder strengthening to improve proximal control
- Manual therapy, including soft tissue mobilization and neural gliding if needed
- Grip strength training and return-to-function drills
- Ergonomic assessment and activity modification
We use standardized outcome tools such as the Patient-Rated Elbow Evaluation (PREE) and pain-free grip strength as measurable indicators of progress.
When to Refer to Physiotherapy
- Persistent medial elbow pain (>2–3 weeks)
- Recurrence of symptoms despite rest or medication
- Functional limitations in gripping, lifting, or sport
- Previous failed corticosteroid injection
- Pre- or post-injection rehabilitation
Conclusion
Medial epicondylalgia is often under-treated or mismanaged as an inflammatory condition. Evidence from RCTs strongly supports eccentric-based physiotherapy and manual therapy for effective and sustained recovery. Early referral can optimize outcomes and help patients avoid unnecessary medications or surgical interventions.
References:
Tyler, T. F., Thomas, G. C., Nicholas, S. J., & McHugh, M. P. (2014). Addition of isolated wrist extensor eccentric exercise to standard treatment for chronic lateral epicondylosis: A prospective randomized trial. Journal of Shoulder and Elbow Surgery, 19(6), 917–922. https://doi.org/10.1016/j.jse.2009.05.031
Seo, J. B., Kang, J. H., Lee, J. H., Lee, S. Y., & Kim, H. S. (2013). Effects of exercise therapy and manual therapy on pain and function in patients with medial or lateral epicondylitis: A randomized controlled trial. Journal of Physical Therapy Science, 25(5), 551–554. https://doi.org/10.1589/jpts.25.551
