Hi, I’m Dr Eric Cobb of Z-Health Performance. Today we are beginning a new series dealing with golfer’s elbow.  We just finished up a long series on tennis elbow a few weeks ago and in that process, I got a lot of requests saying, “Hey Doc, can you talk also about golfer’s elbow?”  So for the next six weeks or so we’re going to be discussing different approaches for dealing with that from a brain-based perspective. 

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Now, let’s talk about golfer’s elbow, also known as medial epicondylitis, so if my palms are facing forward and I have pain here, alright, on the inside of my elbow this is called medial epicondylitis.  It’s commonly referred to as golfer’s elbow but you do not have to be a golfer to suffer from it.  In fact, a lot of people involved in tennis, overhead sports and other occupational activities that require a lot of gripping will develop medial epicondylitis.  So what we want to do is spend some time talking about how to deal with it.

So first thing I want to discuss, number one is don’t stop moving.  While rest is very useful for helping decrease the pain, one of the things we’re going to hopefully share with you is that pure rest will not train the tissues so that you can go back to your activities.  So number one, I want to make sure that you don’t stop activities but number two, we do need to begin grading them.   What does that mean?  It means that we want to avoid high speed and high force movements or we want to only do enough that we can manage whatever discomfort we’re experiencing.  So in other words, what I tell people is, let’s say you developed golfer’s elbow from playing tennis and you go out and you play a, you know, a normal match with your regular playing partner and for the next three days your elbow’s killing you.  Well obviously that’s too much.  What you may find that you can go out and just hit ground strokes for practice for 45 minutes and within 24 hours your pain’s back to a relatively comfortable level.  That’s going to be your benchmark.  So the second thing I need you to remember is you’re going to decrease the amount of forceful, high-speed activities that you’re performing and then you need to make sure that if you do anything, that within 24 hours you’re back to a relatively normal or comfortable level of discomfort.  Those are going to be two of the kind of key elements.  

Now, whenever we start talking about how are we going to fix this problem?  What’s the rehabilitative process look like?  They’re going to be two major factors that we want to discuss. Factor number one, is improving local tissue capacity.  Meaning we need to strengthen the muscles we need to help deal, hopefully, with increasing some tendon stiffness, tendon strength as well.  So we’re going to cover that section of this information a little bit later as we go through the series because the second element that comes into all of this is improving kinetic chain function.  What does that mean?  It basically means that most people that develop golfer’s elbow, particularly from sports activities, do so because there are other parts of their body that are not moving as freely and as well as they should be.  So we’re going to start today by focusing on the spine. 

There are several studies looking at people that develop medial epicondylitis in overhead sports, particularly throwing a baseball, or pitching, playing tennis, serving, and volleyball. Whenever we look at those individuals one of the things that becomes very evident is a lack of thoracic extension as well as a lack of rotation.  So, whenever we say thoracic, we’re talking about the mid-back.  Experientially, for us, what we found is that if we were working on the thoracic spine, very quickly people will begin to notice, that if they go out and play they have a greater capacity to perform the shorter activity with less pain.  So here’s how we’re going to do it.  Today most people that have menial epicondylitis can generate pain simply by taking a firm grip, right, you may have to grab onto something but you can just squeeze and get an idea of how much discomfort you have.   The other option is to take your thumb and dig around on that medial elbow and find the most tender spot.  We’re going to use this as a guide because what we’re going to do is, we’re going to say, “okay, if I press for that hard that’s a level 5 out of 10 pain.”   We’re going to do a little bit of thoracic work and then we’re going to retest because most of you will find immediately that if we start working on thoracic mobility, as well as some strengthening of the shoulder, that you’ll notice some immediate decrease in that pain.  So what we want to focus on, is again for today, working on thoracic rotation.  That is experientially, as I said, that’s one of the number one things that we find a deficit in.  So, here’s how we’re going to do it, there are lots and lots of thoracic exercises out there where you lay on the ground and you do these windmill type exercises.  Those are super useful, however what I like to have people do is to think about, when do I have the issue?  Well, I have the issue typically when I’m standing and moving.  So, we’re going to begin working on thoracic mobility in a standing position.  What we’re going to do first is, we’re going to imagine someone’s pushing on our chest.  We’re going to flex forward and then we’re going to imagine that there’s a ball here and we’re going to push it forward.  So, we’re just basically doing thoracic flexions and extensions.  Alright, I want you to do five to ten of those.  

Once you’ve done that, I then want you to just try to move the thoracic spine side to side.  This is going to feel very strange to a lot of people,alright?  But after you’ve done that, you’re then going to try and make circles, just like I would make a circle with my head and neck.  We’re going to try and make thoracic circles and I’m doing all this in a neutral stance.  You do five in one direction, five in the opposite direction.  It does not matter in the beginning if you can do this very comfortably and very smoothly.  Over time your coordination and motor control will improve.  Right now what’s important is, you make the effort. 

Now from there, we’re going to work on thoracic rotation.  So I want you to get nice and tall and then I want you to bend your knees slightly, tuck your pelvis to begin with.   Now from here, I want you to just rotate to the right and then rotate to the left.  Get an idea of what your comfortable level of rotation is.  To really figure out your comfort rotation, you’re probably going to have to do five to ten repetitions.  This first go around, I want your head and body moving together.  Alright, we’re going to try and keep the pelvis relatively still and rotate head and neck in the trunk.  After you’ve done five to ten repetitions to the right and to the left, I want you to go back and now palpate or squeeze.  Get an idea did that decrease or change the pain in your elbow at all?  Now, what most people will find is that if they work on a little bit of thoracic mobility unloaded, they will eventually hit a wal,l where they are unable to make any further progress.  That’s often the limit that they actually reach in their sporting activity.  So in other words, if I’m hitting a tennis forehand or I’m hitting a golf ball, my rotations that I can actively achieve with kind of just comfortable unloaded movement, will be similar to what I achieve in the sport.  That may not be sufficient.  So, what we do is we mobilize unloaded first.  

Now we’re going to do isometric exercises.   In order to do this, you’re going to need some kind of equipment.  Generally, I like to use a strap or a rope. So, what I have over here, this is one of my handy dandy straps.  I love these.  This is called a Forearm Forklift and you can buy it at almost any hardware store for moving furniture but it’s great because it’s got these nice little loops in here.  They’re padded and they are designed to go on the arm on the forearm or even on the shoulder.  So, let’s imagine that I’m having difficulty with right thoracic rotation.  What I’m going to do is, I’m going to slip my right arm into the loop, I’m going to take a nice comfortable wide stance, and I’m simply going to now keep my arm by my side and I’m going to do some right rotation.  And I’m just going to rotate against that resistance.  Rotate against that resistance. I’m going to hold for 6 to 10 seconds, and then I’m going to relax.  Now here’s where it gets important, based on where the strap is, I now need to change my body position so I’m now going to turn toward that arm.  Alright, and so now I’m going to rotate again seven to ten seconds, six to ten seconds, doesn’t really matter.  And then I’m going to rotate my body in the opposite direction.  And now I’m going to rotate again.  Every time we do this, we’re trying to again, change how much rotation is available to us and we’re trying to get tension on the spine’s spinal musculature in different angles.  So after I’ve done that, I’ll then go back to my first rotation.  95% of people we do this with, will find that their rotation has improved significantly after the isometric.  

So, the rule is first, do unloaded mobilizations.  Then do isometric mobilizations or isometric strength work, drop the strap go back to your mobilizations and then do the isometric work again.  Usually we’re going to do somewhere between 5 and 10 of the isometric holds in different positions.  After you’ve done that with the the band directly to your side, you’re then going to adjust the band.  You’re going to put it lower and higher, so eventually we’ll be doing rotations like we were directly across.  We’re then going to be rotating downward and we will also be rotating upward against the resistance, because whenever we’re working on thoracic mobility, we need to have different angles included in that process to more closely mimic what we’re going to have to do in a sporting activity.  So this is kind of the starting point in terms of improving the kinetic chain portion of dealing with medial epicondylitis.  After you’ve gone through that whole protocol, go back and check your arm again.  Hopefully what you’ll found, not only has your rotation improved, but also your pain will improve.  One of the things that’s nice about this is, that you can do it every day.  You’re not going to fatigue yourself because it’s a very low amount of load, so you can actually practice this in the morning.  Practice it in the evening.  So if you do this every day, for roughly one to two weeks, you’re going to find a significant increase in your thoracic mobility and as that is achieved, hopefully, we’ll be able to carry that over into your sporting activity and decrease pressure on that medial elbow. 

So this is video number one in our golfers elbow relief series.  We will be back next week with some additional information for you looking at the hip.