Table of Contents
- 1. Introduction
- 2. Tennis Elbow vs. Golfer's Elbow (At a Glance)
- 3. What is Tennis Elbow? (Lateral)
- 4. What is Golfer's Elbow? (Medial)
- 5. Pathophysiology: Tendinosis vs. Tendinitis
- 6. Causes & Risk Factors
- 7. Signs and Symptoms
- 8. Diagnosis & Special Tests
- 9. Medical Management
- 10. Physiotherapy Management
- 11. Detailed Exercise Protocol
- 12. Clinical Pearls for Students & Clinicians
- 13. Frequently Asked Questions (FAQ)
- 14. References
1. Introduction
Elbow pain is one of the most frequent complaints in outpatient physiotherapy clinics. While many patients label any outer elbow pain as "Tennis Elbow," there is a counterpart that affects the inner elbow known as "Golfer's Elbow." Both are types of epicondylalgia, but they affect different muscle groups, different tendons, and require different rehabilitation strategies.
This guide explains the key differences between Lateral Epicondylitis (Tennis Elbow) and Medial Epicondylitis (Golfer's Elbow) to help you identify which one you have and how to treat it effectively.
2. Tennis Elbow vs. Golfer's Elbow (At a Glance)
| Feature | Tennis Elbow (Lateral) | Golfer's Elbow (Medial) |
|---|---|---|
| Location of Pain | Outside of the elbow (Lateral Epicondyle) | Inside of the elbow (Medial Epicondyle) |
| Primary Muscle Involved | Extensor Carpi Radialis Brevis (ECRB) | Pronator Teres & Flexor Carpi Radialis |
| Painful Movement | Wrist Extension (Lifting up) & Gripping | Wrist Flexion (Bending down) & Squeezing |
| Prevalence | Common (1-3% of population) | Less Common (0.4-1% of population) |
3. What is Tennis Elbow? (Lateral)
Medically known as Lateral Epicondylalgia, it affects the common extensor tendon. The pain is triggered when you use your forearm to lift objects, type, or grip. Despite the name, most cases are caused by repetitive occupational tasks rather than sports.
4. What is Golfer's Elbow? (Medial)
Golfer’s Elbow (Medial Epicondylitis) is an overuse injury affecting the tendons on the inside of the elbow. These tendons attach the flexor muscles—those used to flex the wrist and clinch the fingers—to the medial epicondyle.
Pain is usually felt when shaking hands, flexing the wrist against resistance, or swinging a golf club (specifically the "trailing" arm). In some cases, because the Ulnar Nerve runs right behind the medial epicondyle, Golfer's Elbow can be associated with numbness or tingling in the ring and little fingers.
5. Pathophysiology: Tendinosis vs. Tendinitis
Modern histology confirms that both conditions are usually Tendinosis—a degenerative process—rather than Tendinitis (inflammation). This means the tendon has tiny micro-tears and disorganized collagen fibers due to a failed healing response. Treatment must therefore focus on "loading" the tendon to stimulate repair, rather than just "resting" it to stop inflammation.
6. Causes & Risk Factors
- Repetitive Strain: Frequent use of tools, heavy lifting, or high-volume typing.
- Sporting Technique: Flawed golf swings (hitting the ground) or "late" tennis backhands.
- Weightlifting: Heavy "pulling" exercises (deadlifts, rows) without adequate grip strength often lead to Medial Epicondylitis.
- Smoking and Obesity: Both reduce blood supply to tendons, significantly slowing down the healing process.
8. Diagnosis & Special Tests
Physiotherapists use provocative tests to confirm the diagnosis:
For Tennis Elbow (Lateral):
- Cozen’s Test: Pain with resisted wrist extension and radial deviation.
- Maudsley’s Test: Pain with resisted middle finger extension.
For Golfer's Elbow (Medial):
- Medial Epicondylitis Test: The therapist passively supinates the forearm and extends the wrist and elbow. A positive test reproduces pain at the medial bony bump.
- Resisted Wrist Flexion: Pain when the patient tries to curl their wrist against resistance.
10. Physiotherapy Management
Management for both follows a similar three-phase approach:
- Pain Management: Activity modification, counterforce bracing, and potentially ESWT (Shockwave Therapy) to jumpstart healing in chronic cases.
- Loading Phase: Progressive eccentric and isometric strengthening.
- Return to Sport/Work: Sport-specific drills and ergonomic adjustments (e.g., vertical mouse for office workers).
11. Detailed Exercise Protocol
For Tennis Elbow (The "Tyler Twist"):
Use a FlexBar or a rolled-up towel. Twist the bar with the healthy hand, grasp with the painful hand, and slowly untwist using the painful hand (eccentric control).
For Golfer's Elbow (The "Reverse Tyler Twist"):
Similar to the above, but focused on wrist flexion. Hold the bar vertically, twist it into flexion with the good hand, and slowly control the "un-curling" with the injured medial flexors.
💡 Clinical Pearls for Students & Clinicians
- Ulnar Nerve Involvement: In Medial Epicondylitis, always perform a Tinel's sign over the cubital tunnel. If the patient has "funny bone" sensations, it may be Ulnar Neuritis rather than simple Golfer's Elbow.
- Kinetic Chain: Elbow issues are often caused by shoulder weakness. If the rotator cuff is weak, the forearm muscles have to work harder to stabilize the arm, leading to overuse. Always screen the shoulder.
- Isometric Loading: If a patient is in too much pain for eccentric movement, start with 30-45 second isometric holds (holding a weight still) to provide an analgesic (pain-relieving) effect.
13. Frequently Asked Questions (FAQ)
Q: Can I have both Tennis and Golfer's Elbow at the same time?
A: Yes, it is possible, though rare. This is often seen in manual laborers who perform heavy gripping combined with repetitive twisting (e.g., using a screwdriver all day).
Q: Is a brace helpful?
A: Yes, a counterforce brace can help by distributing pressure away from the tendon insertion. For Tennis Elbow, place it 2cm below the outer bone; for Golfer's Elbow, 2cm below the inner bone.
14. References
- Reinares DP, et al. Tennis Elbow vs. Golfer's Elbow: A comparative review of tendinopathies. Journal of Orthopaedics.
- Tyler TF, et al. The "Tyler Twist" and "Reverse Tyler Twist" in clinical practice. North American Journal of Sports Physical Therapy.
- Magee DJ. Orthopedic Physical Assessment. Elsevier.
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