What are the first-line treatments for medial epicondylitis (golfer's elbow)?

First-Line Treatment for Golfer's Elbow (Medial Epicondylitis)

Begin with conservative management consisting of relative rest with activity modification, NSAIDs (oral or topical), ice application for 10-minute periods, counterforce bracing, and progressive eccentric strengthening exercises with wrist flexor stretching. 1, 2

Initial Conservative Management (0-4 Weeks)

Activity Modification and Rest

• Modify or temporarily stop activities that aggravate symptoms while continuing activities that don't worsen pain 2
• Avoid complete immobilization as this leads to muscular atrophy and deconditioning 2
• For golfers specifically, consider larger club grips and graphite shafts to reduce strain 3

Pain Control Measures

• Apply ice through a wet towel for 10-minute periods to provide effective short-term pain relief 2
• Use NSAIDs (oral or topical) for pain relief 1, 2
• Topical NSAIDs reduce tendon pain while avoiding gastrointestinal risks associated with oral formulations 2
• Note that NSAIDs effectively relieve pain but may not affect long-term outcomes 1, 2

Bracing

• Apply medial counterforce bracing (similar to tennis elbow bands but positioned medially) to reinforce, unload, and protect tendons during activity 2, 3

Rehabilitation Phase (2-8 Weeks)

Exercise Therapy

• Initiate eccentric strengthening exercises for the wrist flexors to promote tendon healing and increase strength 2
• Perform stretching exercises for the wrist flexors, which are widely accepted and helpful 2
• Tensile loading stimulates collagen production and guides normal alignment of newly formed collagen fibers 2
• Continue bracing as needed during this phase 2

Important Caveats

What to Avoid

• Do not rely heavily on corticosteroid injections as first-line treatment 1, 2
• While corticosteroid injections may be more effective than NSAIDs in the acute phase, they do not alter long-term outcomes 1
• Corticosteroids may inhibit healing, reduce tendon tensile strength, and potentially predispose to spontaneous rupture 2
• Avoid complete immobilization which leads to muscle atrophy 2

When to Escalate Treatment

• If symptoms persist despite 4-8 weeks of well-managed conservative treatment, consider second-line modalities such as corticosteroid injection, extracorporeal shock wave therapy, or deep transverse friction massage 2
• If pain persists despite 6-12 months of conservative management, surgical evaluation may be warranted 2

Equipment Modifications for Golfers

• Larger, softer club grips reduce strain on the medial epicondyle 3
• Graphite shafts absorb more shock than steel shafts 3
• Proper swing technique evaluation may be necessary to address biomechanical contributors 3