What exercises and strengthening methods are recommended for medial epicondylitis?

Exercises and Strengthening Methods for Medial Epicondylitis

Eccentric strengthening exercises combined with stretching are the most effective treatment approach for medial epicondylitis, focusing on the wrist flexor and pronator muscle groups to reduce symptoms, increase strength, and promote tendon healing. 1

Understanding Medial Epicondylitis

Medial epicondylitis, also known as "golfer's elbow," affects the flexor-pronator muscle group that attaches to the medial epicondyle of the humerus. It is less common than lateral epicondylitis, occurring in approximately 0.3-0.6% of men and 0.3-1.1% of women 2. The condition typically affects individuals aged 40-60 years and can result from:

• Repetitive wrist flexion and pronation movements
• Sports activities such as golf, baseball, javelin throwing, volleyball, and climbing
• Household activities and do-it-yourself projects 3

Recommended Exercise Program

Stretching Exercises

• Wrist Flexor Stretch: Extend arm with palm up, use opposite hand to gently pull fingers back toward body until stretch is felt in forearm
• Pronator Stretch: With elbow extended, use opposite hand to rotate forearm into supination until stretch is felt
• Hold each stretch for 30-60 seconds (longer duration beneficial for older persons)
• Perform 2-3 days per week for optimal benefits 1

Eccentric Strengthening Exercises

1. Eccentric Wrist Flexion:

   • Sit with forearm supported on table, palm facing up
   • Hold light weight (start with 1-2 pounds)
   • Use opposite hand to assist in raising the weight
   • Slowly lower the weight over 3-5 seconds
   • Perform 1 set of 8-15 repetitions initially, progressing to 2-3 sets

2. Eccentric Pronation:

   • Sit with forearm supported, holding a light weight or hammer
   • Rotate forearm to palm-up position with assistance
   • Slowly rotate to palm-down position over 3-5 seconds
   • Perform 1 set of 8-15 repetitions, progressing to 2-3 sets

Exercise Parameters

• Frequency: 2-3 days per week with at least 48 hours between sessions 1
• Intensity: Start with light resistance, gradually increase when current weight becomes manageable
• Repetitions: 8-12 for strength development, 15-20 for muscular endurance
• Sets: Begin with 1 set, progress to 2-4 sets as strength improves
• Technique: Perform exercises in a rhythmical manner at moderate to slow controlled speed, moving through full range of motion without overextending 1

Progressive Rehabilitation Protocol

Phase 1: Acute Phase (1-2 weeks)

• Rest from aggravating activities
• Gentle stretching of wrist flexors and pronators
• Light isometric exercises (no movement, just tension)
• Ice application after exercise

Phase 2: Intermediate Phase (2-4 weeks)

• Continue stretching
• Begin eccentric strengthening with light weights
• Gradually increase resistance as tolerated
• Add wrist curls and pronation/supination exercises

Phase 3: Advanced Phase (4+ weeks)

• Progress to functional strengthening exercises
• Incorporate sport or activity-specific movements
• Gradually return to normal activities

Additional Treatment Modalities

Physical Modalities

• Deep transverse friction massage may help reduce pain 4
• Ultrasound therapy shows moderate evidence of effectiveness versus placebo on mid-term follow-up 5
• Laser therapy may be effective in some cases 5

Supportive Measures

• Use of proper supportive footwear during exercise
• Stay hydrated before, during, and after exercise
• Consider counterforce bracing to reduce tension on the affected tendon

Important Considerations and Precautions

• Avoid breath-holding (Valsalva maneuver) during exercises by exhaling during exertion phase and inhaling during relaxation phase 1
• Avoid ballistic stretching (bouncing during stretches) as it increases risk of injury 1
• Always warm up for 5-10 minutes before stretching or strengthening exercises 1
• Monitor for warning signs such as increased pain, swelling, or decreased range of motion
• If symptoms persist despite a well-managed conservative treatment trial (typically 6-8 weeks), referral to an orthopedic surgeon may be warranted 4

Return to Activity Guidelines

• Return to normal activities should be gradual
• Modify activities that involve repetitive wrist flexion and pronation
• Full return to sports activities may take up to 8 months in some cases 3
• Consider technique modification in sports to reduce stress on the medial epicondyle

By following this structured approach to exercises and strengthening for medial epicondylitis, patients can effectively manage symptoms and improve function while promoting proper tendon healing.