Golfer's Elbow: The Tendon Problem on the Inner Side

The medial epicondyle is the bony prominence on the inner side of the elbow. It is the attachment point for the common flexor-pronator tendon, the shared origin of muscles that flex the wrist, flex the fingers and pronate the forearm (turning the palm downward). Every time you grip, throw, pull, or turn a screwdriver, these muscles load this tendon. The muscles involved are pronator teres, flexor carpi radialis, palmaris longus, flexor digitorum superficialis, and flexor carpi ulnaris. They share a common origin at the medial epicondyle, and the tendon that anchors them there is the site of the problem.

Golfer’s elbow, formally called medial epicondylitis, is pain at this attachment. It is the medial counterpart to tennis elbow (lateral epicondylitis), which affects the extensor tendon on the outer side. Medial epicondylitis is about 3 to 10 times less common than lateral epicondylitis, affecting approximately 0.4 percent of the adult population [1]. Despite the name, golf is one of the less common causes. Repetitive manual work, throwing sports, climbing, and weightlifting (particularly movements involving heavy wrist flexion or forearm pronation under load) are more frequent triggers.

What Is Happening

As with tennis elbow, the “-itis” suffix is misleading. Chronic medial epicondylitis is not an inflammatory condition. It is a tendinopathy: the tendon has undergone structural changes including disorganized collagen, increased ground substance, and angiofibroblastic degeneration, but inflammatory cells are absent [3]. The pathological process is identical to what occurs on the lateral side. The distinction between inflammation and degeneration matters because it changes the treatment logic. Anti-inflammatory strategies (rest, ice, corticosteroid injection) address a process that is not present in the chronic phase. What the tendon needs is mechanical stimulation to trigger remodeling of the disorganized collagen, and that is the basis for progressive loading as the primary treatment.

The most commonly affected structure is the pronator teres and flexor carpi radialis origin. The flexor digitorum superficialis may also be involved [2]. The severity and extent of tendon involvement varies: some patients have a localized area of degeneration at the tendon’s attachment to bone, while others have more diffuse changes extending into the muscle belly.

The ulnar nerve is an important neighbor. It runs in the cubital tunnel, directly behind the medial epicondyle. In approximately 50 percent of patients with medial epicondylitis, there is concurrent ulnar nerve irritation [5]. This produces tingling or numbness in the ring and little fingers, and potentially weakness in grip strength. If nerve symptoms are present, they need to be addressed alongside the tendon problem. The proximity of the ulnar nerve also makes the medial epicondyle a riskier location for corticosteroid injection than the lateral side: the nerve can be inadvertently contacted during the injection, though careful technique avoids this.

What the Evidence Supports

The evidence base for medial epicondylitis treatment is smaller than for lateral epicondylitis, but the underlying tendon pathology is the same, and the treatment principles are the same [3]:

Progressive tendon loading through eccentric and isometric exercises is the primary treatment. While the randomized trial evidence is from the lateral side [4], the application to medial epicondylitis follows from the shared pathology. Eccentric wrist flexion exercises are the medial equivalent of the eccentric wrist extension exercises used for tennis elbow. The mechanism is that controlled mechanical loading stimulates the tendon cells (tenocytes) to produce organized collagen, gradually replacing the disorganized, degenerative tissue with structurally sound tendon. The loading must be progressive: starting below the pain threshold and gradually increasing load, speed, and volume over weeks. The tendon adapts slowly; this is not a one-week fix.

Isometric exercises provide pain relief and serve as a starting point when eccentric loading is too painful. A sustained isometric contraction (holding against resistance without movement) produces an analgesic effect that can last for several hours, making it a useful tool for managing symptoms while the tendon remodels under the progressive loading program.

Corticosteroid injection provides short-term relief (4 to 6 weeks) but the same concerns apply as with lateral epicondylitis: short-term gain with potential for worse long-term outcomes compared to no injection [2]. The injection suppresses the pain signal, which may encourage premature loading before the tendon has remodeled, and the corticosteroid itself may inhibit collagen synthesis. My read of the current evidence is that injection is reasonable when pain is severe enough to prevent participation in a loading program, but it should be followed by a structured rehabilitation period, not treated as the end point.

Activity modification is important in the acute phase. Identify and modify the aggravating activity. For weightlifters, this may mean reducing wrist flexion during curls and pull-ups, using a neutral grip instead of a supinated grip, or reducing training volume temporarily. For throwing athletes, it may require a period of relative rest from throwing. For manual workers, ergonomic adjustments (larger grip diameter, reduced force requirements) can reduce the load on the common flexor tendon. Modification does not mean complete rest: complete rest deloads the tendon, and a deloaded tendon loses capacity, making it more vulnerable when activity resumes.

Bracing (a counterforce strap placed over the common flexor muscle belly, a few centimeters distal to the medial epicondyle) may reduce tendon loading during activity. The strap works by dispersing the force over a broader area and changing the fulcrum of the muscle contraction slightly, reducing peak stress at the tendon attachment. The evidence is limited to clinical experience rather than randomized trials, but the mechanism is plausible and the intervention is low-risk.

How This Relates to the Kinetic Chain

The elbow is a stability joint in the joint-by-joint framework: its primary job is to transmit force between the shoulder (a mobility joint) and the wrist (a mobility joint) while keeping the forearm in a controlled position. When the wrist or shoulder lacks the mobility or control to absorb load properly, the elbow compensates. A thrower with reduced shoulder internal rotation may increase the valgus stress at the elbow during the acceleration phase. A climber with poor shoulder mechanics may overgrip to compensate for inefficient body positioning, concentrating load at the medial epicondyle. Addressing the tendon alone, without examining the chain above and below it, is treating the symptom. If the shoulder or thoracic spine is stiff, or the scapular stabilizers are weak, the tendon loading pattern that caused the problem will recur once the patient returns to the activity that provoked it.

Exercises to Try

Isometric wrist flexion. Rest the forearm on a table, wrist off the edge, palm facing up. Use the other hand to resist as you push the affected fist upward (into wrist flexion). Hold for 30 to 45 seconds at approximately 70 percent of maximal effort. Three sets. This loads the flexor tendon without eccentric stress and provides the analgesic effect of sustained isometric contraction. It is the appropriate starting exercise when the tendon is too irritable for eccentric work.

Eccentric wrist flexion. Hold a light dumbbell (0.5 to 2 kg), forearm on a table, wrist off the edge, palm facing up. Use the unaffected hand to curl the weight up into wrist flexion. Then slowly lower the weight using only the affected hand over a count of 5. Three sets of 10. The load is on the lowering phase, which is the eccentric (lengthening) contraction that provides the strongest stimulus for tendon remodeling. Increase weight when the current load can be completed without significant pain (a mild ache during or after is acceptable; sharp pain is not).

Forearm pronation with resistance. Hold a hammer by the middle of the handle. Starting with the palm facing sideways (neutral), slowly rotate the forearm palm-down (pronation) against the weight of the hammer head. Return slowly to neutral using both hands, then repeat. Three sets of 10. This specifically loads the pronator teres, which is one of the most commonly affected muscles in medial epicondylitis. Progress by gripping the hammer closer to the end of the handle, which increases the lever arm and the resistance.

Grip strengthening. Squeeze a tennis ball or grip strengthener, holding for 5 seconds. Three sets of 10. Use a moderate grip that does not provoke significant pain. Grip strength is commonly reduced in medial epicondylitis and needs to be restored as part of the rehabilitation process. Gripping activates the flexor digitorum superficialis and profundus, both of which cross the wrist and contribute load to the medial epicondyle.

Wrist flexor stretch. Extend the affected arm in front of you, palm up. Use the other hand to gently pull the fingers downward (into wrist extension) with the elbow straight. Hold for 20 to 30 seconds. Three repetitions. This stretches the flexor-pronator group. Perform after the strengthening exercises, not as a substitute for them. Stretching alone does not provide the mechanical stimulus needed for tendon remodeling, but it can reduce muscle tightness that increases resting tension on the tendon.

When to See a Doctor

See a doctor or physical therapist if:

• There is numbness or tingling in the ring and little fingers (ulnar nerve involvement)
• Pain has not improved after 8 to 12 weeks of consistent progressive loading
• There is significant weakness in grip
• Pain came on suddenly during a throw or lift (possible tendon avulsion, which may require surgical repair)
• The elbow is stiff, locked, or catching (may indicate a different problem such as loose bodies or osteoarthritis)

When to see a doctor. If joint pain follows a significant injury, is accompanied by swelling, giving way, locking, or loss of range of motion, or if you have neurological symptoms (numbness, tingling, weakness), see a doctor or physical therapist. They can assess whether imaging or specialist input is appropriate.