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STILL IN MOTION
Because slowing down isn’t in the plan.
THIS WEEK'S STORY
After the tennis elbow issue ran, a reader named Chris wrote in with one line: can you please address medial epicondylitis?
He was not the only one. Several of you asked the same question in slightly different words. Some of you play golf. Some of you play tennis and hit a heavy topspin forehand. One of you does not play anything at all and simply spent thirty years turning a wrench for a living.
That is the tell. The inside of the elbow does not care what you call the activity. It cares how much gripping and forearm rotation you have asked of it, for how long, and how well the tissue has kept up.
The frustrating part is that medial epicondylitis is less common than the lateral version, which means it gets less coverage, fewer conversations at the club, and less confident advice. So people default to what they have heard about tennis elbow — brace it, ice it, rest it — and then wonder why they are still hurting eleven months later.
The good news is that the underlying story is the same one we told in Issue #44. The bad news is that the inside of the elbow is more stubborn about it, and there is a nerve back there that changes the conversation entirely if it gets involved.
THE MAIN MESSAGE
Medial epicondylitis is a tendon degeneration problem, not an inflammation problem — the same as its more famous cousin on the outside of the elbow.
On the lateral side, the wrist extensors pull at the outside of the elbow. On the medial side, it is the flexor-pronator group — the muscles that curl the wrist and rotate the palm downward — pulling at their common origin on the medial epicondyle. Two decades of tissue research point to the same conclusion in both locations: what you are dealing with is disorganized, degenerated collagen, not an active inflammatory fire.
That single fact reorganizes the entire treatment plan. Anti-inflammatory approaches — ice, NSAIDs, cortisone — quiet symptoms temporarily without changing the tissue. Progressive mechanical loading, and specifically eccentric loading, is what stimulates the tendon to remodel.
Where the medial side differs:
It is less common. Medial epicondylitis accounts for a clear minority of elbow tendinopathy cases, which is why most people have never heard the protocol described.
It is more stubborn. The literature consistently shows longer timelines to resolution than the lateral side. Eight weeks is a floor, not a finish line. Twelve to sixteen is a realistic window.
Grip and forearm rotation matter more. The flexor-pronator group is the primary gripping and pronating unit of the forearm, so the daily load never really stops — opening jars, carrying grocery bags, holding a phone, gripping a steering wheel.
The ulnar nerve runs directly behind the medial epicondyle. This is the single most important anatomical difference, and it is the reason this issue leads with a clinician referral rather than closing with one.
The Nerve Caution, Stated Plainly
Numbness, tingling, or weakness in the ring finger and little finger is not tendinopathy. That is a nerve signal, and it needs a clinician's hands and eyes on it before you load anything. The same is true of pain that radiates down the forearm into the hand, or a persistent pins-and-needles feeling that wakes you at night.
Tendinopathy pain is local, mechanical, and predictable — it hurts when you grip, it hurts when you press on the bump on the inside of the elbow, and it settles when you stop. Nerve pain behaves differently. If what you have does not match the first description, this newsletter is not the right resource for you this week. Your physician is.
WHY IT SHOWS UP AFTER 60
Four contributors, each of which compounds the others:
Grip strength decline. As grip strength falls (Issue #22), the flexor-pronator group works closer to its ceiling to accomplish the same task. A club, racket, or bag that felt weightless at 45 now demands a meaningfully higher percentage of available capacity.
Reduced tendon tolerance. Tendon turnover slows with age. The same weekly volume that the tissue absorbed comfortably for decades begins to outpace its ability to repair.
Technique drift in the golf swing. Casting, early release, and hitting from the top all transfer load from the body to the hands and forearms. A steep, handsy downswing with a divot taken behind the ball is one of the highest-load patterns for the medial elbow that exists in the game.
Equipment mismatch. A grip that is too small forces a tighter squeeze to control the club, which raises flexor-pronator tension on every swing of every round. Grips harden with age and get slicker, which produces the same effect by a different route.
The Treatment Hierarchy
Progressive eccentric loading of the flexor-pronator group. This is first and it is not close.
Grip and equipment adjustment — grip size, grip condition, shaft flex, and for racket players, string tension.
Technique modification to move load from the arms back into the body's rotation.
Cortisone injection as a short-term pain management tool only, not a curative intervention, and used sparingly given what repeated injection does to tendon tissue.
Surgery as a last resort after twelve months of genuinely consistent conservative care.
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STRETCH OF THE WEEK
Seated Wrist Flexor Stretch with Elbow Extension and Supination
Why: This targets the flexor-pronator musculotendinous junction — the tissue involved in medial epicondylitis — with the elbow straight and the forearm turned palm-up, which is the position of maximum stretch for the flexor origin at the medial epicondyle. The supination is what separates it from a standard wrist flexor stretch and what makes it specific to the medial side. It is the mirror image of the extension stretch that ran in Issue #44.
How to do it:
Sit at the edge of a chair, affected arm extended in front of you, elbow straight, palm facing up
With the opposite hand, gently pull the fingers and palm downward and back toward the floor until a stretch is felt along the underside of the forearm
Hold 30 seconds — the stretch should run from the wrist up toward the inside of the elbow, not just in the hand
Release, then rotate the forearm slightly further into palm-up position and repeat for a deeper angle at the origin
2 rounds per arm, twice daily when managing active symptoms
If any part of this produces tingling into the ring or little finger, stop and see a clinician. That is a nerve signal, not a stretch signal.
Part 2 on Tuesday goes deeper with three flexor-pronator stretches in the sequence clinicians use for medial elbow management, plus the warm-up versus cool-down question that most people get backwards.
STRENGTH MOVE OF THE WEEK
Eccentric Wrist Flexion (Reverse Tyler Twist)
Purpose: The same eccentric loading principle that resolves lateral elbow tendinopathy, reversed to load the flexor-pronator tendons. Slow lowering under load stimulates the tendon to remodel toward healthier, more organized collagen — something no amount of rest accomplishes on its own.
How to do it (light dumbbell version, no FlexBar required):
Hold a light dumbbell of 1 to 2 pounds in the affected hand, forearm resting on a table, palm facing upward, wrist just past the edge
Use the unaffected hand to assist the wrist into full flexion, curled upward toward the forearm
Remove the assisting hand and slowly lower the wrist over 4 to 5 seconds until it is fully extended, hanging back toward the floor
Use the assisting hand to return to the flexed position and repeat
The only active movement is the slow lowering — the assisting hand does all of the lifting
15 reps, 3 sets, twice daily
Expect mild discomfort during the exercise that clears within 24 hours. That is the working range and it is not a sign that something is going wrong. Sharp pain, or soreness that lingers past a day, means the weight is too heavy. Reduce it and continue rather than stopping.
Part 3 on Thursday covers three loading progressions — isometric, eccentric, and combined eccentric with pronation — and the specific criteria for moving from one to the next.
SUGGESTED EQUIPMENT
The FlexBar is the tool used in the original Tyler Twist research on the lateral side, and the same bar performs the reverse version for the medial side. It provides a combination of grip load and forearm rotation that produces a more complete eccentric stimulus than a dumbbell alone, because it loads the pronators along with the flexors rather than the flexors in isolation.
The red bar is the light tension and is where most adults should begin. Green is the next step up. Available at physical therapy supply stores and online for roughly twenty dollars.
Part 4 on Saturday covers the full medial elbow toolkit, the grip sizing question that matters more than anything else on this list for golfers, counterforce brace placement for the medial side specifically, and the complete twelve-week protocol.
SIM60 receives no commissions or affiliate compensation for any equipment referenced in this issue. All mentions are for illustration purposes only.
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THE TAKEAWAY
Golfer's elbow is a tendon degeneration problem on the inside of the elbow, driven by the flexor-pronator group. It responds to the same eccentric loading principle as tennis elbow, on a longer timeline. Rest and ice manage symptoms. Load changes tissue. And because the ulnar nerve sits directly behind the medial epicondyle, anything involving numbness or tingling in the ring and little fingers goes to a clinician first.
YOUR TURN
Have you dealt with pain on the inside of the elbow — from golf, from racket sports, or from work that has nothing to do with either? Did anyone ever describe it to you as a loading problem rather than an inflammation problem? Reply and tell me. Chris asked the question that produced this series, which is a good reminder that the best issues come from readers who read closely enough to ask.
Still moving forward,
— The SIM60 Team
simsixty.com · Because slowing down isn't in the plan.
Educational content only. Not medical advice. SIM60 is not a medical provider and does not diagnose or treat any condition. Consult your physician or a licensed physical therapist regarding your specific symptoms before beginning any exercise described here.
