Physiotherapy and Golf injuries – Part 4 – The Elbow
In the fourth and final article of this series on injuries common in golfers of all abilities, ETPI.com’s Nigel Tilley – a Consultant Physiotherapist on The European Tour – examines elbows injuries in golf and how physiotherapy can help.
The golf swing requires the creation and transfer of forces from the legs, trunk and upper limbs through to the club head. Our hands are the sole pieces of anatomy that connect with the equipment and ultimately link the forces we create to the club head and ball at impact.
The act of swinging a golf club requires golfers to grip the club with both hands. A large number of powerful muscles and complex motor patterns enable us to do this. Our hands are incredible pieces of human engineering, designed for extreme dexterity yet able to produce, resist and control very large forces.
However, producing and tolerating these forces can lead to problems in the tissues of the hands, wrists and elbows that are involved. This is particularly evident if the activity is very repetitive, involves poor technique or is something the tissues have not developed the capacity to tolerate.
The elbow is a commonly injured area in both amateur and professional golfers. Studies suggest 12 per cent of acute injuries and 7-10 per cent of chronic injuries in professional golfers are at the elbow. Interestingly this rises to 15-33 per cent of injuries in amateur golfers. For both amateurs and professionals, women seem to have a higher incidence of elbow injuries than male golfers.
Technique and swing faults are potential reasons for the higher incidence of elbow injuries in amateur golfers. A technique that requires much more work from the hands and wrists throughout the swing is seen commonly.
Restrictions in flexibility and range of movement in the hips, trunk and shoulders can mean that swing and club head speed are generated largely from the elbows/wrists in amateurs. Professional golfers have greater flexibility and strength in these regions and are able to generate and transfer forces from the ground up through the legs and trunk rather than purely from the forearms and hands.
Tennis elbow (lateral epicondylitis)
What is it?
Surprisingly, ‘golfer’s elbow’ isn’t seen as commonly in golfers as ‘tennis elbow’! This is mainly due to its poor labelling and a big change in the techniques and equipment used in golf over the years.
Golfer’s elbow traditionally affects the structures on the medial (inside) of the elbow, whereas tennis elbow affects the structures on the lateral (outside) of the elbow. Golfers are actually much more likely to suffer from injuries to the outside of the elbow region in what is most often referred to as ‘tennis elbow’.
Although called lateral epicondylitis, this is commonly a misnomer, as in general the tendons do not show signs of inflammation but rather angiofibroblastic degeneration, collagen disarray and hypoxic tendon degeneration. This often occurs due to rapid increase in loading and or continued excessive loading due to training or technique faults that the tissues are unable to adapt to.
The Extensor Carpi Radialis Brevis (ECRB) tendon is the structure usually involved, close to its attachment on the lateral epicondyle (the bony prominence on the outside of the elbow).
People will often present with a slow onset of soreness on the outside of the elbow. This frequently occurs a day or two after hitting a lot of practice balls, playing on hard ground/mats or suddenly increasing the amount of golf/balls hit in a short period of time. The pain can also be sharp and severe, catching them during aggravating movements. This pain can occur when playing, during day-to-day activities that involve simple or forceful gripping techniques, lifting/carrying or other sports.
How does physiotherapy treat this type of condition?
The type of physiotherapy management will depend on the stage of the problem and your individual presentation. Often this type of injury will require ‘load modification’ with more sudden onset injuries requiring immediate removal of load and PRICE protocol (protection, rest, ice, compression and elevation) or POLICE (protection, OPTIMAL LOADING, ice, compression, elevation).
Invariably the onset can be linked to a sudden increase in load or repeated excessive loading such as the following:
- hitting a lot of practice balls in a short period of time
- changing swing or grip
- hitting off hard ground/mats
- going from relative periods of inactivity (a few weeks without play) to high periods of sudden golf activity (e.g. playing three rounds in three days and hitting many practice balls)
Increasing the ability of the tissues to tolerate loads and re-model can be achieved through structured exercises; isometric (the muscle is working but not lengthening), eccentric (the muscle works while lengthening) and concentric (the muscle works while shortening) exercises. Your physiotherapist will be able to advise you on the correct exercises depending on the stage and severity of your presentation.
By gradually increasing the load and volume and progressing the exercises, the tissues can adapt to better withstand the forces going through them.
Other treatment techniques include the use of manual therapy to the elbow and associated tissues and structures, devices called epicondylar clasps and taping techniques that can help to offload the injured area to aid its recovery.
Understanding the cause can often help in identifying other ways to manage/resolve the injury and prevent its reoccurrence. These could include modification of poor swing technique and practice habits, changing the thickness of the grips in the golf clubs and/or stiffness of the shafts, or carrying out appropriate conditioning, training and flexibility treatment and programmes with your physiotherapist.
Restriction in hip and thoracic spine mobility can place increased demand on the hand/wrist and forearm to perform and generate more of the force required in the golf swing, rather than this being generated and transferred from the legs, hips, trunk and shoulders. Subsequently this can make golfers more prone to injuries of the elbow and wrist.
It is important that you warm up properly each and every time before you play golf to prepare your body for the activity it is about to do. A warm up should last 10-15 minutes and involve increasing blood flow, heart rate, activating the muscles involved in the swing and in controlling the spine, and in stimulating the body’s motor control mechanisms. This will help prepare you for playing golf and help reduce your risk of injury.
Reviewing your practice and play habits can also help identify and direct your golfing activity more appropriately, to reduce the effects of overload.
For safety, optimum treatment and to reduce the risk of re-injury, players and patients should visit and complete a full assessment of all injuries and receive treatment and rehabilitation under the guidance of a chartered physiotherapist.
Keep an eye out for an upcoming article on the management of tendinopathies to find out why we don’t recommend steroid injections!