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GOLFERS ELBOW - MEDIAL EPIDCONDYLITIS

Golfer's Elbow

If you experience pain when performing gripping tasks such as washing your hair, and pain is on the inside of your elbow, you are likely suffering from medial epicondylitis which is also known as golfer’s elbow or climber’s elbow. Medial epicondylitis usually comes on gradually over time and is an uncomfortable niggle with recurrent stiffness in the morning before it develops into a painful injury causing loss of function. Most elbow movements will be pain-free, however specific gripping movements are painful.

Important note: It is normal to feel some pain during and/or after rehab sessions, however it is best to judge this level of pain. 0 is when you feel no pain at all and 10 is excruciating pain. The pain you feel throughout rehab and exercise should not be more than 3/10. In addition, pain should not be worse the following morning or 24 hours after your session. If this is the case you have done too much and overloaded the tendon.

Click any exercise to play

TRAINING CONSIDERATIONS

Immediate management – straight after suffering injury
Immediate management – straight after suffering injury
 • You should refrain from activities that exacerbate pain, especially those that require repetitive wrist flexion (bending wrist forwards) and forearm pronation (palm facing downwards to the ground).

• Icing can alleviate pain as well as decrease swelling if this is present.

• Isometric exercises listed below help to reduce pain.


Massage
Massage – 5 minutes over painful area/s of muscle daily
 • Massage techniques applied to both the tendon and the connecting muscles on the inside of the forearm and elbow is helpful in some individual suffering golfer’s elbow.• Applying massage to the muscles on the inside of the forearm can help reduce tension and tightness in these muscles. This will improve their function which long-term should help reduce the strain on the tendon at the elbow. Find points in the muscles that produce more pain and target these points with your massage.

• Massage to the tendon (as seen in the video) is sometimes used. However, individuals respond differently to this and therefore it can cause more pain in some people. If this is the case, don’t continue aggravating and irritating the tendon and stop further massage of the tendon


Heat and Ice
Heat and Ice
 • 20 minutes of heat as required during the day to decrease muscle tension and relax muscles (no after exercise)• Ice for 20 minutes following strengthening

Stretching
Stretching – 2 X 30 seconds daily
Prayer stretch

Outstretched arm stretch

Weighted stretch in four-point-kneel

TRAINING PROGRAM

Stage 1
Stage 1 Make sure you have no pain at the elbow that is above 3/10.
Isometrics need to be performed before strengthening exercises when these are progressed to and undertaken.
Exercise Key Points
Isometric wrist extension Gradually build up to 45 seconds X 5
Twice daily
2 mins rest between each set

TENNIS ELBOW - LATERAL EPIDCONDYLITIS

Tennis Elbow

Tennis elbow is the common name for ‘lateral epicondylitis’ which is associated with pain on the outside of the elbow. It is a tendinopathy and not an inflammatory disorder. The forearm is made up of two major muscle groups. The muscles on the inside/palm side of the forearm are called the wrist flexors and the muscles on the back/outside are called the wrist extensors. When climbing, the wrist flexors are overworked by repeated and sustained gripping. Therefore, the wrist flexors are very strong and tight, whereas the wrist extensors are weaker and underdeveloped. This imbalance can lead to an overuse injury of the weakened extensor muscles. The most common site of this injury is on the outside of the elbow called the lateral epicondyle, hence the name of the condition. It is characterised as an overuse injury and pain is increased over time with repeated movement loading the tendons of these extensor muscles. It is aggravated by daily activities including using your mouse and undoing jar lids.

Important note: Grip strength is stronger when the wrist is extended backwards 35 °. Individuals often bend their wrists too far backwards while grasping holds, leading to overuse of their weakened wrist extensors. This can become a further problem when progressing to climbing harder routes and needs to be considered throughout rehab and return to training and sport.

Important note: It is normal to feel some pain during and/or after rehab sessions, however it is best to judge this level of pain. 0 is when you feel no pain at all and 10 is excruciating pain. The pain you feel throughout rehab and exercise should not be more than 3/10. In addition, pain should not be worse the following morning or 24 hours after your session. If this is the case you have done too much and overloaded the tendon.

Click any exercise to play

TRAINING CONSIDERATIONS

Immediate management
Immediate management – straight after suffering injury
• You should refrain from activities that exacerbate pain, especially those that require repetitive wrist extension (bending wrist backwards).

• Icing can alleviate pain as well as decrease swelling if this is present.

• Isometric exercises listed below help to reduce pain.


Massage
Massage – 5 minutes over painful area/s of muscle daily
• Massage techniques applied to both the tendon and connecting muscles can be helpful in individuals suffering from tennis elbow.

• Applying massage to the muscles on the outside of the forearm can help reduce tension and tightness in these muscles. This will improve their function which long-term should help reduce the strain on the tendon at the elbow. Find points in the muscles that produce more pain and target these points with your massage.

• Massage to the tendon (as seen in the video) is sometimes used. However, individuals respond differently to this and therefore it can cause more pain in some people. If this is the case, don’t continue aggravating and irritating the tendon and stop further massage of the tendon.


Heat and Ice
Heat and Ice
 • 20 minutes of heat as required during the day to decrease muscle tension and relax muscles (no after exercise)• Ice for 20 minutes following strengthening

Stretching
Stretching – 2 X 30 seconds daily
Prayer stretch

Outstretched arm stretch

Weighted stretch in four-point-kneel

TRAINING PROGRAM

Stage 1
Stage 1 Make sure you have no pain at the elbow that is above 3/10.
Isometrics need to be performed before strengthening exercises when these are progressed to and undertaken.
Exercise Key Points
Isometric Wrist Extension Gradually build up to 45 seconds X 5
Twice daily
2 mins rest between each set

SHOULDER IMPINGEMENT

Shoulder Impingement

Shoulder impingement is thought to be a symptom of an over-use injury such as bursitis or tendinopathy of one of the rotator cuff muscles (Supraspinatus, Infraspinatus, Teres Minor & Subscapularis). Though the pathophysiology is still unclear, the pain is likely due to the increased nerve density around the tendon. The pain causes secondary rotator cuff dysfunction (pain in other muscles). There are 3 categories of impingement:
1) Primary external impingement
2) Secondary external impingement
3) Internal impingement
Primary external impingement: Reduction subacromial space (where the shoulder blade & collar bone meet) from abnormalities such as osteophyte formation (bone spurs).
Secondary external impingement: Reduction subacromial space from poor muscle stabilization of the scapula (shoulder blades).
Internal impingement: compression of the postero-superior surface of the glenoid (back of the shoulder).
Brukner, P. (2012). Brukner & Khan’s clinical sports medicine. North Ryde: McGraw-Hill.

Click any exercise to play

TRAINING CONSIDERATIONS

Phase 1 - Sub Acute
PHASE 1 Sub -Acute
1. Physio – Assessment to determine type of impingement, location of impingement & what is being impinged
2. Exercise Physiologist – Set plausible return date, outline plan and modify training programExample: Shoulder Impingement Syndrome –
Grade I Supraspinatus Tear in Subachromial Space
Keys
• Determining diagnosis from professional, as your injury may have a completely different rehab pathway
• Remove aggravating activities from training & avoid them in everyday activity if possible
• Shoulder-specific exercise is most effective treatment, manual therapy, corticosteroid injection & taping may assist but are not primary rehab strategies.
Training Modifications
Rest & protect injury site
Continue gym program where possible e.g. single arm and lower body
Continue conditioning work where possible e.g. bike
Checklist to progress to Phase 2
1. Pain free Passive ROM
2. Pain <2/10

Phase 2 - Acute
PHASE 2 - Acute
1. Exercise Physiologist – Review progress, modify program where necessary & begin return to running program
Keys
• Begin scapular and progress to rotator cuff exercises
• Gradually improve active ROM aiming for full ROM. See attached program for example
Training Modifications
Gradually re-introduce upper body training, minus overhead activities & ensuring pain is <2/10.
Checklist to progress to Phase 3
1. Full, pain free Active ROM
2. VAS <2/10 with activity

Phase 3 - Functional
PHASE 3 - Functional
1. Exercise Physiologist – Review progress, modify program where necessary & begin return to running program
Keys
• Re-integrate regressions of key ninja movements e.g. assisted pull ups to assist with returning to jumping onto object & holding/swinging
• Progress scapular & rotator cuff exercises
• Re-integrate low level power exercises into program
See attached program for example
Training Modifications
Discuss & assess with your coach what movements you are capable of training for at the moment and put together a plan.
Checklist to progress to Phase 4
1. No pain or discomfort during training
2. No major strength & power deficits e.g. <10% difference b/w arms in weight lifted in pressing & pulling exercises e.g. <10% difference b/w arms w/ max single arm underarm tennis ball throw
3. Relatively pain free training e.g. swing on bar & jump and land in 4pt

Phase 4 - Return to Ninja
PHASE 4: Return to Ninja
1. Exercise Physiologist – Review progress, modify program where necessary & begin return to running program

Continue progressing with Strength & Conditioning program (see attached), progressing towards max strength & power training, as scapula-humeral kinematics will most likely still need improving, and strength & power deficits will need to be addressed.

 

TRAINING PROGRAM

Week 1
Phase 1: Sub-Acute Session 1
Exercises Sets x Reps Weight Rest | Tempo
1 Shoulder Pendulums 2x12 BW
2. Trigger Post Shoulder + Gentle Sleeper Stretch 2x10 ES BW 2mins | Slow
3. Isometric Wall Shoulder Ex Rotation 3x30s ES BW Pain Free
4. Banded Sidelying Ext Rotation 2x8 ES Light 2mins | Slow
5. Hollow Hold 4x20s BW 90secs
6. Arch Hold 3x15s BW 90secs
7. Scap Setting 2x20 BW Pain Free
8. Stick Assisted Range of Motion 2x10 EW Light

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