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It is amazing how many articles out there discuss Golfer’s Elbow without actually diving into the golf swing. The main reason for this is that most cases of Golfer’s Elbow are actually unrelated to sport. In all reality, if we were going to pick a sport to name this injury after it probably should have been “Baseball Elbow.” Nonetheless, resolving Golfer’s Elbow requires the right treatment plan and a better understanding of the golf swing.
What Is The Cause of Golfer’s Elbow?
The fancy name for Golfer’s Elbow is Medical Epicondylitis, which basically implies that the inner part of the elbow is inflamed. This is often due to repetitive loading of the forearm muscles that causes micro-tearing at the tendon on the inner aspect of the elbow. This can lead to weakening of the tendon and scar tissue build up. You tend to see this injury in people with more laborious jobs like carpentry, plumbing and construction. Typically because of the repeated gripping combined with elbow motions.
It’s a tough injury to combat because most people do not have the luxury of eliminating the cause of their pain. Carpenters need to keep building, plumbers need keep the pipes clean and Golfer’s… well, most golfer’s have a slight addiction to the game and can’t imagine not playing. Sadly, in order to see some improvement you will need to temporarily get your fix from some old Master’s highlights.
Why Does Golfer’s Elbow Happen to Golfers?
In Golfer’s, this injury tends to occur somewhere during the downswing. In both novice and experienced golfer’s this injury is likely from overuse and/or hitting the ball off of harder surfaces like turf mats with less than perfect form. From my experience, this tends to be a high handicapper problem for reasons that I will explain below.
Golfer’s Elbow in the Low Handicapper
Let’s start with the low handicapper. In reality, this injury will likely be an overuse injury. However, if you want to nerd out a little bit we can’t overlook the fact that pitchers and golfers create a very similar arm position. In the picture below, the strain being placed on the elbow is pretty obvious. The majority of golfers will not experience this level of strain based on the fact that the elbow is much closer to the body. Also, the shoulder does not rotate nearly as much and the club is being swung with two arms rather than one.
The force being placed on the elbow is called a “valgus-extension force.” In pitchers, the elbow is straightening quickly as the pitch is delivered. Straightening of the elbow also occurs in the golf swing as the club moves into impact. The degree of straightening tends to differ from one player to another. In the golfer, this straightening of the elbow will not provide a great deal of strain on the elbow, unless of course you are throwing the club into the ground and hitting “fat” shots, as the high handicapper will often do.
Golfer’s Elbow In The High Handicapper
In the higher hanidcap golfer the risk of developing Golfer’s Elbow is greater because of poor sequencing in their golf swing that typically leads to an improper impact position. 3-D motion analysis shows that the correct sequence in the swing is lower body first, followed by the trunk, then the arms and finally the club. Less skilled golfers will often initiate the swing with their trunk and the club. This results in all sorts of compensations at the moment of impact.
Proper Release of The Golf Club
Rather than hitting the ball first and then the grass, most higher handicap golfers with actually hit behind the ball. This is called a “fat” or “heavy” shot because their divot is behind the ball. Hitting the ball “heavy” or “fat” will generate a greater amount of force and trauma at the elbow compared to proper ball first contact.
With “fat” shots we typically see people performing a “chicken wing” or “scooping” motion at impact. Rather than telling you all the things you could do wrong at impact let’s talk about what you could be doing right. To fix this problem we need to call on a golf professional to help us better understand how to properly “release the golf club” in your downswing. To clarify what “release” means I will call on Swing Coach Michael Breed.
*This picture is demonstrating what proper release is based on Michael Breed’s description below.
“Here are the basics on the release. The golf club should appear as if it is pulling your arms through. Both of your forearms will have rotated, so your left hand will be visible- you can see the fingers of my left hand beneath my right hand. If your arms have not rotated sufficiently and have come through impact stiff rather than loose, you wont be able to see you left hand under the right. Further, improper rotation of the forearms will separate your left elbow from the side of your body – this is called a “chicken wing.” -Michael Breed, The Picture Perfect Golf Swing (pg. 121).
Another common result of improper release is the “scooping fault.” Let’s call on Michael Breed again. In regards to top tour professionals, “what is most apparent is that the club shaft has a forward lean at impact. It is my belief that because of the instinct to assist the ball, the average player generally has the club shaft pointing toward the center of right side of their body at impact rather than at the left hip, making it impossible to have a straight line from the left shoulder through to the club head.” -Michael Breed, The Picture Perfect Golf Swing
Golf Fix For Golfer’s Elbow
To correct this problem you obviously want to make sure that it is actually a problem in your swing. Recording your swing with video can be a great way to identify subtle and obvious faults in your swing. If this is something you would like to try I recommend Michael Breed’s book, The Picture Perfect Golf Swing. In this book he shows you how to set up your camera, what to look for and some drills for correcting it. I would also encourage you to work with a golf professional that can guide you in the process.
Here are two drills from the Titleist Performance Institute that can help you better understand how to properly release the golf club.
Steps For Resolving Pain
Step 1: Resolve Inflammation & Restore Elbow Motion
The strategies below are meant to promote healing and minimize the inflammatory process.
Nutrition
Avoid foods that are linked to higher levels of inflammation. The inflammatory process can be a good thing. However, in some scenarios the degree of swelling and inflammation may be excessive or prolonged. We don’t want to contribute to the problem. This basically means eat healthier (reduce the table sugar, processed foods and refined carbs). Feel free to sprinkle some turmeric on your food once you are eating clean. Please don’t sprinkle turmeric on a Krispy Kreme Donut.
Medication
Anti-inflammatories like Advil and Ibuprofen have a time and a place, especially with an injury like Golfer’s Elbow. However, they need to be used sparingly because of the potential gastrointestinal side effects and they should not be used as a preventative measure. For instance, I see too many people that take Advil before a round of golf or a gym session to minimize future pain.
Immobilization
In the majority of cases, I would not recommend immobilizing the elbow. If wearing an elbow brace or elbow compression sleeve relieves pain have at it. When you are out of the sleeve or brace you need to make sure you are elbow to fully bend, straighten and rotate you elbow (we will discuss more below).
Ice
I recommend frequent use of ice to help relieve pain. Shoot for 2-3x/day in the early stages of the injury. As swelling starts to resolve you can back off. This is a great alternative to drugs and may even help reduce swelling. Apply for 15 minutes, as needed. I do not recommend use of heat, especially if the elbow is clearly inflamed and swollen.
Electrical Stimulation (TENS Unit)
Electrical Stimulation may be helpful for pain relief and promote healing due to increased circulation. If you are looking for a cheap and effective TENS unit I recommend this brand. If you are looking for something that is top of the line I recommend this brand.You can actually apply the electrical stimulation while icing your elbow or while performing the stretching routine below.
Ultrasound
Ultrasound application, which would have to be done in a therapy clinic may also help with healing, but I find its application to be more beneficial for helping loosen up tissues around the elbow before engaging in your exercises. As mentioned above, I am not an advocate of heat while the injury is still actively red and swollen. Once it is no longer inflamed and swollen you may begin to apply heat prior to your exercises.
Soft Tissue and Joint Mobilization
Soft Tissue and Joint Mobilization can do wonders for helping relieve pain and restore elbow motion. Many people are capable of providing these treatments, but I would recommend that you rely on someone with an understanding of rehabilitation principles. I look at treating an injury like remodeling a house. Manual therapy, massage, active release technique, acupuncture, etc. are the equivalent of throwing on some nice paint. It’s important, but we still need some other knowledge and skill sets to do a quality remodel.
In this article I provide videos that help you perform similar soft tissue treatments on your own.
Stretches
Elbow: Our primary goal is to gently restore motion at the elbow. This means being able to bend and straighten the elbow, as well as rotate (pronation and supination) at the elbow. Rotation at the elbow is a critical piece in your golf swing that allow you to make a proper backswing and release of the club. Check out this video by Titleist that goes into more detail.
Wrist: It is also important to look above and below the elbow. Limitations in motion at these joints can actually prevent you from swinging properly. Poor flexibility at your wrist may actually lead to compensation in your swing that places increased stress on the elbow. To see if you are missing motion in your wrists check out the Wrist Flexion Test and Wrist Extension Test.
Shoulder: Similarly, limitations in shoulder motion may also impose increased strain on your elbow. If you have had injuries to your shoulders or wrists in the past you may never get full motion, and that is ok. The goal is to optimize what you have available to you. Many professional golfers have limited flexibility and their swings show it. Regardless, they find a way to get back to a good impact position. To check your shoulder motion check out The 90/90 Test.
Wrist, Elbow and Shoulder Stretches
To see videos of each exercise go to my-exercise-code.com using code: UH6MVL9
Step 2: Restore Strength and Endurance
Stage 1: Isometric Strength
In an effort to prevent muscle atrophy we start with “isometric resistance” to avoid irritation at the elbow. With isometrics you are basically providing resistance to a joint without actually moving the joint.
Prescription: Perform 5 sets x 10 repetitions of the following exercises for 6-8 second holds, 1-2x/day at sub-maximal resistance (50-80% effort). These movements should NOT result in pain. If they do, start with a more gentle level of resistance.
To see videos of each exercise go to my-exercise-code.com using code: UH6MVL9
Stage 2: Full Motion Strength
Caution: Before progressing to this phase of strength you should have pain free elbow motion and minimal tenderness to touch around the elbow.
Prescription: Start with 2 sets x 10 reps of each exercise and slowly progress to 5 sets x 10 repetitions WITHOUT weight. If you can do this without pain and in a controlled fashion add a 1 lb. weight. Start at 2 sets x 10 repetitions again and gradually progress back to 5 sets x 10 repetitions. Slowly increase the weight by no more than 2-3 lbs. at time.
To see videos of each exercise go to my-exercise-code.com using code: UH6MVL9
Stage 3: Advanced Upper Body Strength
Before progressing to this stage you should have no pain or tenderness to touch around the elbow and approximately 70% strength in the arm compared to the unaffected side. This is obviously hard to gauge by yourself, but I think you are intuitive enough. If you have some doubts, schedule a session with a physical therapist who can to get a thorough evaluation.
To simplify this stage of the program I am introducing you to the “Throwers Ten Program.” You may be asking yourself, “Why am I going to do a throwing program?” The throwing motion and golf swing actually have a lot of the same characteristics. Throwing drills are often used in golf to give people a better understanding of what the swing should feel like. The best part is that we have already reviewed many of the exercises in this program.
You can find the program here, Thrower’s Ten Program.
Prescription for Thrower’s Ten Program: 3 Sets x 15 Reps [Find a weight that allows you to perform no less 15 reps and no more than 20 reps].
Interval Sports Program for Golf
This protocol was taken from a paper in the Journal of Orthopaedic and Sports Physical Therapy titled “Interval Sports Program: Guidelines For Tennis, Baseball and Golf.” In this paper the authors write “The golfer is encouraged to begin using each club with a tee to avoid the deleterious forces that may be produced during a divot. Swings are initiated at partial effort and progressed to full effort as tolerated.”
Caution: Before initiating this program you should be able to move your elbow freely in all directions without pain. You should also be able to perform the isometric strength exercises listed above without pain.
If at any point in the protocol you begin to experience pain, return to the previous week. You should not have pain while playing.
Other Questions & Considerations:
“Should I use an elbow brace or elbow sleeve to help with pain?”
As we mentioned above, this is not necessary. However, some people report increased comfort with use of a compression arm sleeve when first returning back to their sport or job.
“Should I use Arnica, Icy Hot, CBD Oil or some other type of pain relief cream/oil?”
These creams may help bring temporary relief, but please do not use them as a crutch to return to golf. Similar to Advil, do not rely on these treatments as preventative measures.
“I am not seeing progress. Who should I see first?”
I would strongly suggest that you see a skilled Physical Therapist to get a proper evaluation. If you have attempted the recommendations above without success I would recommend that you follow up with an Orthopedic or Sport’s Medicine Doctor. Most physicians will want to see that you tried conservative treatment before attempting any imaging or invasive procedures. First line treatment for many physicians will be oral anti-inflammatory medication and/or cortisone injection at the elbow. Other treatments include Platelet Rich Plasma (PRP) Injection which has recently gained more popularity.
Other Potential Causes of Elbow Pain
One reason to see a Physical Therapist or Physician is to make sure the injury is actually Golfer’s Elbow. Other potential sources of pain at the inner part of the elbow are listed below.
Cubital Tunnel Syndrome: Entrapment and/or irritation of the ulnar nerve. Radiating pain, numbness and/or tingling are commonly associated with a nerve injury. The symptoms may actually travel down or up the arm. We have to be more gentle when treating this injury and it requires a slightly different protocol than the one provided above.
Neck Injury: In some instances a “pinched nerve” at the neck may actually be causing pain at your elbow. If you find that neck motion or shoulder shrug motions trigger your symptoms it may be the neck that needs to be treated.
Ulnar Collateral Ligament Tear: This is more severe than Golfer’s Elbow. We are no longer dealing with a bout of inflammation and micro-tearing at the elbow. Tearing of the ulnar collateral ligament leads to instability at the elbow, making you more prone to repeated injury, especially with golfing. This is an injury commonly seen in baseball players. Many baseball players will actually opt for Tommy John Surgery to repair the ligament because of it’s high success rate and potential for increased velocity on their pitches post surgery.
Medical Imaging
X-Ray will be helpful for ruling out injuries related to the bone, such as fractures. This will often be the first type of medical imaging that you receive when visiting your physician.
MRI is better for detecting injuries to soft tissue, like ligaments, tendons and muscle. However, many insurances will not approve this until you have tried conservative treatment.
Ultrasound has been shown to be effective for looking at soft tissue injury as well. The benefit is that it’s more accessible, quicker and cheaper to use.
Conclusion
Here is a quick recap of today’s article:
- The fancy name for Golfer’s Elbow is Medical Epicondylitis, which basically implies that the inner part of the elbow is inflamed. This is often due to repetitive loading of the forearm muscles that causes micro-tearing at the common flexor tendon on the inner aspect of the elbow.
- Limitations in strength and flexibility at your wrist, elbow and shoulder can be responsible for this injury. In some cases limitations in lower body and trunk flexibility could also lead to increased strain on the elbow during your golf swing.
- Understanding the proper swing sequence and how to get in a good impact position is critical for preventing this injury.
- Proper progression of your rehabilitation program is important for optimizing healing and improving strength of the tissues at the inner part of the elbow. The first goal is to reduce inflammation and restore motion at your elbow. From there, we need to gradually restore strength of the tissues surrounding the elbow.
References:
Kiel J, Kaiser K. Golfers Elbow. [Updated 2019 Apr 16]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK519000/
Journal of Orthopaedic & Sports Physical Therapy 2015 45:11, 938-949