A controlled clinical pilot trial to study the effectiveness of ice as a supplement to the exercise programme for the management of lateral elbow tendinopathy

Background

The use of ice as a supplement to an exercise programme has been recommended for the management of lateral elbow tendinopathy (LET). No studies have examined its effectiveness.

Objectives

To investigate whether an exercise programme supplemented with ice is more successful than the exercise programme alone in treating patients with LET.

Methods

Patients with unilateral LET for at least four weeks were included in this pilot study. They were sequentially allocated to receive five times a week for four weeks either an exercise programme with ice or the exercise programme alone. The exercise programme consisted of slow progressive eccentric exercises of wrist extensors and static stretching of the extensor carpi radialis brevis tendon. In the exercise programme/ice group, the ice was applied after the exercise programme for 10 minutes in the form of an ice bag to the facet of the lateral epicondyle. Patients were evaluated at baseline, at the end of treatment, and three months after the end of treatment. Outcome measures used were the pain visual analogue scale and the dropout rate.

Results

Forty patients met the inclusion criteria. At the end of treatment there was a decline in visual analogue scale of about 7 units in both groups compared with baseline (p<0.0005, paired t test). There were no significant differences in the magnitude of reduction between the groups at the end of treatment and at the three month follow up (p<0.0005, independent t test). There were no dropouts.

Conclusions

An exercise programme consisting of eccentric and static stretching exercises had reduced the pain in patients with LET at the end of the treatment and at the follow up whether or not ice was included. Further research to establish the relative, absolute, and cost effectiveness as well as the mechanism of action of the exercise programme is needed.     

Effects of stretching on passive muscle tension and response to eccentric exercise

BACKGROUND: Stretching is used in an attempt to improve performance and reduce the risk of muscle injury, with little evidence to support its effectiveness. HYPOTHESIS: Four weeks of static or ballistic stretching can attenuate the increased soreness and decreased flexibility seen after eccentric exercise. STUDY DESIGN: Controlled laboratory study. METHODS: Twenty-nine male subjects were randomly assigned to a static stretching, ballistic stretching, or control group. On each of 4 consecutive days, they completed 4 maximal range of motion stretches using a Cybex isokinetic dynamometer to passively stretch the hamstrings at 0.087 rad.s(-1) (5 deg.s(-1)). Stiffness from 0.87 to 1.48 rad (50 degrees -85 degrees ), peak range of motion, work absorption, peak resistive torque, and soreness were measured. Participants then completed 4 weeks of either static or ballistic stretching for a total stretching duration of 3600 seconds. After training, the 4 days of testing were repeated with an eccentric exercise task added after day 1. RESULTS: Stretching groups had an increase in range of motion and stretch tolerance after 4 weeks of stretching, with no change in muscle stiffness, work absorption, or delayed onset muscle soreness. After eccentric exercise, they also had greater range of motion and stretch tolerance than did controls. CONCLUSION: Both static stretching and ballistic stretching increase range of motion, most likely as a result of enhanced stretch tolerance rather than changes in muscle elasticity. Four weeks of stretching maintain range of motion and stretch tolerance in the days after eccentric exercise.     

The effects of stretching on strength performance

Strength and flexibility are common components of exercise programmes; however, it is not clear how best to include both of these elements in a single training programme. It is common practice among athletes, coaches and recreational exercisers to perform a stretching routine before a strength training session. Stretching exercises are regularly recommended, even in many textbooks, with the claimed purpose of preventing injury and muscle soreness, or even enhancing performance. However, as highlighted in recent review articles, this recommendation lacks scientific evidence. Thus, the purpose of the present review is to determine the acute and chronic effects of stretching on strength performance, together with the underlying mechanisms. Although most studies have found acute decreases in strength following stretching, and that such decreases seem to be more prominent the longer the stretching protocol, the number of exercises and sets, and the duration of each set have, in general, exceeded the ranges normally recommended in the literature. Consequently, the duration of the stimuli were excessively long compared with common practice, thus making evident the need for further studies. In addition, when recommending flexibility exercises, one should consider other underlying issues, such as the safety of the participants, possible increases in injury risks and the unnecessary time expenditure. Many mechanisms underlying stretching exercises still demand investigation so that links between the observed effects, their causes and the consequences may be constructed.     

Developing a Stretching Program

In brief: Although stretching exercises can prevent muscle injuries and enhance athletic performance, they can also cause injury. The author explains the four most common types of stretching exercises and explains why he considers static stretching the safest. He also sets up a stretching routine for runners. In setting up a safe stretching program, one should (1) precede stretching exercises with a mild warm-up; (2) use static stretching; (3) stretch before and after a workout; (4) begin with mild and proceed to moderate exercises; (5) alternate exercises for muscle groups; (6) stretch gently and slowly until tightness, not pain, is felt; and (7) hold the position for 30 to 60 seconds.     

Eccentric exercise in treatment of Achilles tendinopathy

AIM: Prognosis and treatment of Achilles tendon pain (achillodynia) has been insufficiently studied. The purpose of the present study was to examine the long-term effect of eccentric exercises compared with stretching exercises on patients with achillodynia. METHODS: Patients with achillodynia for at least 3 months were randomly allocated to one of two exercise regimens. Exercise was performed daily for a 3-month period. Symptom severity was evaluated by tendon tenderness, ultrasonography, a questionnaire on pain and other symptoms, and a global assessment of improvement. Follow-up was performed at time points 3, 6, 9, 12 weeks and 1 year. RESULTS: Of 53 patients with achillodynia 45 patients were randomized to either eccentric exercises or stretching exercises. Symptoms gradually improved during the 1-year follow-up period and were significantly better assessed by pain and symptoms after 3 weeks and all later visits. However, no significant differences could be observed between the two groups. Women and patients with symptoms from the distal part of the tendon had significantly less improvement. CONCLUSIONS: Marked improvement in symptoms and findings could be gradually observed in both groups during the 1-year follow-up period. To that extent this is due to effect of both regimens or the spontaneous improvement is unsettled.     

Effect of stretching on strength loss and pain after eccentric exercise

PURPOSE: The purposes of the this study were to determine whether stretch-induced strength loss was muscle length dependent (study 1) and whether passive stretching prior to eccentric exercise affected strength loss and pain on subsequent days (study 2). METHODS: For study 1, knee flexion strength was measured isometrically (six angles) and isokinetically (eccentric and concentric) in 10 men (33 +/- 9 yr). The subjects then performed six 90-s static hamstring stretches, after which isometric and isokinetic strength were retested. For study 2, the dominant and nondominant legs of eight men (34 +/- 9 yr) were assigned to a stretch (six 60-s stretches) or control condition prior to eccentric hamstring exercise. Isometric strength and pain were assessed prior to, immediately after, and on the 3 d after exercise. RESULTS: After stretching, strength was decreased by 17% at 80 degrees , 11% at 65 degrees , 5% at 50 degrees , 7% at 35 degrees , and 8% at 20 degrees , and it was increased by 6% at 5 degrees (angle effect P < 0.01). Strength loss following eccentric exercise was less on the stretched versus the unstretched control limb at 37 degrees (P < 0.05), but not at other angles (stretch by time by angle P < 0.01). Pain was not different between the stretched and the unstretched control limb (P = 0.94). CONCLUSION: Stretch-induced strength loss was dependent on muscle length, such that strength was decreased with the muscle group in a shortened position, but not with the muscle group in a lengthened position. Strength loss and pain after eccentric exercise were generally unaffected by prior stretching, with the exception that stretching prevented strength loss when assessed with the muscle in a lengthened position.     

Anterior shoulder dislocations in sports

Anterior shoulder dislocations, primary and recurrent, are among the most disabling injuries to the shoulder that can plague the athlete. The diagnosis is easily made by the following: the physical appearance of the shoulder; loss of capability by the athlete to internally and externally rotate the shoulder with the elbow at his side; by evaluating the mechanism of injury; and x-rays. Anterior shoulder dislocations should be reduced as soon as possible after diagnosis, to minimise the stretching effect on the neurovascular structures while the humeral head is dislocated. The reduction is not done to allow the athlete to return immediately to sport. Use of a simple traction method in the first 10 to 15 minutes following the injury will result in a successful reduction in the vast majority of dislocations. Reduction of the humeral head can be confirmed by the athlete regaining the capability to internally and externally rotate his shoulder with his elbow at his side. Following reduction, the athlete should begin a treatment regimen which includes a restrengthening programme emphasising the muscles of internal rotation and adduction plus rigid restrictions of activities until the goals of the rehabilitation programme are satisfied. The author's experience with this treatment regimen with athletes at the United States Naval Academy, has shown a decrease of the recurrence rate of primary anterior shoulder dislocations to 25% versus the 80% recurrence rate we have become familiar with from studies done which did not stress specific rehabilitation programmes. The athlete should also be instructed in a self-performed traction method for reduction should a redislocation occur, to minimise the stretching effect on the neurovascular structures and allow relief from discomfort. Surgery for primary and recurrent anterior dislocations should only be considered when the athlete fails to achieve the desired goals after participating in a specific, progressive, adequate rehabilitation programme.     

Perceived exertion responses to novel elbow flexor eccentric action in women and men

PURPOSE: The primary aim was to describe perceived exertion responses to different intensities of eccentric exercise in women and men. METHODS: 42 adults (21 men and 21 women, 7 per condition) completed elbow extension exercises with a weight corresponding to 80%, 100%, or 120% of maximal voluntary concentric strength. Total work was equated by manipulating the number of repetitions in the 80% (N = 45), 100% (N = 36), and 120% (N = 30) conditions. RESULTS: A two-way ANOVA showed significant main effects for the intensity and sex factors. Perceived exertion ratings were strongly dependent on exercise intensity, and women reported lower RPEs than men. A separate three-way mixed model ANOVA that included a repetition factor showed that perceived exertion ratings increased similarly across the first 30 repetitions in all exercise conditions. Significant partial correlations were found between mean RPE during the eccentric exercise bout, and the mean intensity of delayed-onset muscle pain measured from 12- to 72-h postexercise after controlling for the relative exercise intensity (r12.3 = 0.28) or the maximum concentric strength of the elbow flexors (r12.3 = 0.33). CONCLUSIONS: 1) for both women and men, there is a positive association between the intensity of eccentric exercise performed with the elbow flexors and RPE; 2) perceived exertion ratings increase significantly then plateau when repeated eccentric muscle actions are performed at constant, submaximal absolute intensities; 3) women rate eccentric exercise performed at the same intensity (relativized to MVC-C) as being less effortful compared with men; and 4) RPE during eccentric exercise can account for a small but significant amount of variability in delayed-onset muscle pain after statistically controlling for differences in strength or relative intensity.     

24种瑞士球练习对腰部竖脊肌和多裂肌激活程度的影响

目的:探讨24种常见的动静态瑞士球练习对腰部竖脊肌和多裂肌激活程度的影响。方法:14名青年男性受试者分别完成10种动态和14种静态瑞士球练习,记录腰部竖脊肌和多裂肌sEMG信号,计算平均肌电振幅(AEMG)并进行标准化处理。按肌肉不同激活程度(0～40%、40～80%、>80%)将24种练习方式分为轻度、中度和重度激活三类,采用单因素方差分析对不同练习方法对腰部竖脊肌和多裂肌激活程度的影响进行分析,采用t检验考察不同支点位置(近端和远端)对仰卧直腿桥式支撑练习时腰部竖脊肌和多裂肌激活水平的影响。结果:不同瑞士球练习时腰部竖脊肌和多裂肌激活程度有显著性差异(P<0.05)。腰部竖脊肌激活程度:重度激活7项,中度激活10项,轻度激活7项;多裂肌:重度激活11项,中度激活7项,轻度激活6项。近端和远端支撑对仰卧直腿桥式支撑练习时腰部竖脊肌和多裂肌激活水平的影响有显著性差异(P<0.05)。结论:不同瑞士球练习对腰部竖脊肌、多裂肌激活程度不同,利用瑞士球练习维持和改善腰部肌肉功能可以根据不同阶段的训练目标选用相应强度的练习方式。     

Effect of elbow joint angle on the magnitude of muscle damage to the elbow flexors

PURPOSE: It has been shown that eccentric actions at a long muscle length result in a larger decrease in force and more muscle tenderness compared with those at a short muscle length. To further investigate the effect of elbow joint angle on the development of muscle damage, this study compared two maximal eccentric exercise regimens in which the starting position of the action was different, but the range of movement was the same. METHODS: One arm of 10 male students performed 24 maximal eccentric actions of the elbow flexors at the elbow joint angle from 0.87 to 2.27 rad (50-130 degrees: S condition) and the other arm at the elbow joint angle from 1.74 to 3.14 rad (100-180 degrees: L condition). Maximal isometric force, range of motion, muscle soreness, plasma creatine kinase activity, upper arm circumference, and B-mode ultrasound pictures of the elbow flexors (US) were measured before and for 5 d postexercise in both conditions. Magnetic resonance imaging (MRI) of the transverse scans of the upper arm was taken at 4 d after exercise. RESULTS: All measures changed significantly (P < 0.01) after exercise for both conditions; however, significantly (P < 0.01) larger changes in the measures were found in the L condition compared with the S condition. MRI and US displayed that only the brachialis was damaged for the S condition but the biceps brachii was also damaged for the L condition. CONCLUSION: The greater development of muscle damage in the L condition compared with the S condition is likely to be associated with the elbow flexors muscles affected by the exercise.     

Overuse injuries in sports. A review

Because knowledge of overuse syndromes is limited, the diagnosis and treatment of these conditions are a challenge to sports medicine physicians. Trial and error methods of treatment and too little attention to basic research have resulted in less than optimum solutions. We do know that these maladies most frequently result from overload or repetitive microtrauma stemming from extrinsic factors such as training errors, poor performance, poor techniques and inappropriate surfaces or intrinsic factors including malalignment and muscle imbalance. Overuse injuries involving the muscles include compartment syndromes and muscle soreness; while those involving the tendons result from a variety of degenerative and inflammatory processes. Overstress of bone results in stress fractures, apophysitis and periostitis. Bursitis and joint overstress problems are also discussed briefly. General guidelines for establishing the appropriate diagnosis are: the initial stages of therapy require rest, often a modification or scaled down exposure to the athlete's usual performance rather than complete abstinence; in acutely symptomatic cases pain medications and various measures to control inflammation may be necessary; an exercise programme should start early with range of motion exercises and isometric muscle contractions; when pain allows, dynamic muscle and flexibility exercises can resume together with a conditioning programme; if possible, eccentric exercises should be performed. The treatment may also include other conservative treatment modalities and surgery in special cases. Overuse injuries constitute a great diagnostic and therapeutic problem because the symptoms are often diffuse and uncharacteristic. An appropriate diagnosis followed by adequate treatment can improve or eliminate most of these conditions, but perhaps even more importantly a proper understanding of overuse syndromes should allow physicians to assist athletes, trainers, and coaches in preventing them.     

Chronic static stretching improves exercise performance

PURPOSE: This study investigated the influence of static stretching exercises on specific exercise performances. METHODS: Thirty-eight volunteers participated in this study. The stretching group (STR) consisted of 8 males and 11 females whose activity was limited to a 10-wk, 40-min, 3-d.wk(-1) static stretching routine designed to stretch all the major muscle groups in the lower extremity. The control group (CON) consisted of 8 males and 11 females who did not participate in any kind of regular exercise routine during the study. Each subject was measured before and after for flexibility, power (20-m sprint, standing long jump, vertical jump), strength (knee flexion and knee extension one-repetition maximum (1RM)), and strength endurance (number of repetitions at 60% of 1RM for both knee flexion and knee extension). RESULTS: STR had significant average improvements (P < 0.05) for flexibility (18.1%), standing long jump (2.3%), vertical jump (6.7%), 20-m sprint (1.3%), knee flexion 1RM (15.3%), knee extension 1RM (32.4%), knee flexion endurance (30.4%) and knee extension endurance (28.5%). The control group showed no improvement. CONCLUSION: This study suggests that chronic static stretching exercises by themselves can improve specific exercise performances. It is possible that persons who are unable to participate in traditional strength training activities may be able to experience gains through stretching, which would allow them to transition into a more traditional exercise regimen.     

The effects of preexercise stretching on muscular soreness, tenderness and force loss following heavy eccentric exercise

The present study sought to investigate the effects of preexercise stretching on delayed onset muscle soreness (DOMS), i.e. soreness, tenderness and loss of muscle force, that usually occurs after strenuous or unaccustomed eccentric exercise. Ten female volunteers performed 10 sets of 10 maximal isokinetic eccentric contractions for knee flexion with both legs after a 5-min ergometer cycling warm-up. Prior to the exercise for one leg, randomly chosen, 4 x 20 s of static stretching for the hamstring muscle group was implemented. Rated soreness, tenderness on algometer pressure and loss of maximal eccentric contractile force was evaluated preexercise and 24, 48 and 96 h postexercise. The exercise bout produced severe DOMS, with parameters peaking and troughing at 48 h postexercise. However, no significant differences were found, regarding any of the parameters, when comparing stretched and nonstretched legs. The present study thus suggests that preexercise static stretching has no preventive effect on the muscular soreness, tenderness and force loss that follows heavy eccentric exercise.     

Effects of warm-up before eccentric exercise on indirect markers of muscle damage

PURPOSE: To test whether active and passive warm-up conducted before eccentric exercise attenuates clinical markers of muscle damage. METHODS: Untrained subjects were exposed to one of five conditions: low-heat passive warm-up (N = 10), high-heat passive warm-up (N = 4), or active warm-up (N = 9), preceding eccentric exercise; eccentric exercise without warm-up (N = 10); or high-heat passive warm-up without eccentric exercise (N = 10). Passive warm-up of the elbow flexors was achieved using pulsed short-wave diathermy, and active warm-up was achieved by concentric contraction. Creatine kinase (CK) activity, strength, range of motion, swelling, and muscle soreness were observed before treatment (baseline) and 24, 48, 72, and 168 h after treatment. RESULTS: High-heat passive warm-up without eccentric exercise did not affect any marker of muscle damage and was used as our control group. Markers of muscle damage were not different between groups that did or did not conduct warm-up before eccentric exercise. The active warm-up and eccentric groups exhibited a greater circumferential increase than controls (P < 0.0002), however, that was not observed after passive warm-up. Additionally, the active warm-up group exhibited a greater CK response than controls at 72 h (P < 0.05). The high-heat passive warm-up before eccentric exercise group exhibited significant change from controls at the least number of time points, but due to a small sample size (N = 4), these data should be viewed as preliminary. CONCLUSION: Our observations suggest that passive warm-up performed before eccentric exercise may be more beneficial than active warm-up or no warm-up in attenuating swelling but does not prevent, attenuate, or resolve more quickly the other clinical symptoms of eccentric muscle damage as produced in this study.     

中医外治法对肘屈肌连续离心训练作功及力矩的影响

为观察中医药外治法对连续离心训练引起的延迟性肌肉酸痛 (DOMS)恢复的作用 ,采用计算机采控的离心训练设备对受试者进行连续 7天伸肘训练产生DOMS ,同时辅以推拿、牵拉、热水浴、盐水浴、中药浴等恢复手段 ,观察屈肘肌作功和力矩等力学指标。结果发现 ,连续 7天离心训练对DOMS产生后肌力的恢复没有明显影响 ,推拿、牵拉、中药浴等手段对DOMS后肌肉力矩和作功有明显的促进恢复的作用。     

Adverse events associated with eccentric exercise protocols: six case studies

PURPOSE: Rhabdomyolysis is a condition characterized by muscle damage and degeneration of muscle cells after strenuous, overexertion exercise. Although the incidence of severe rhabdomyolysis is rare, this condition can be dangerous and even fatal. Eccentric exercise protocols are currently being used to induce and study mild forms of muscle damage. However, serious adverse events can occur in these laboratory investigations. The purpose of this report was to expose some of the adverse events resulting from performance of eccentric exercise protocols to study muscle damage in humans. METHODS: The following case studies involved an eccentric exercise protocol where two sets of 25 maximal eccentric actions of the elbow flexors were performed, separated by a 5-min rest period. RESULTS: Case reports are presented that reveal prolonged losses in the ability of the muscle to generate force lasting 43-47 d, extreme swelling of the exercised arm lasting several weeks, and greatly elevated serum creatine kinase levels. CONCLUSIONS: Although adverse events resulting from eccentric exercise are rare, our laboratory has observed a 3% incidence rate during the past year. Investigators should be knowledgeable of the sequelae of events that are associated with muscle damage after high-force eccentric exercise and take appropriate precautions.     

Can patients with McArdle's disease run?

Patients with McArdle's disease commonly adopt a sedentary lifestyle. This sedentary behaviour, however, usually worsens the limited exercise capacity of these patients. Although eccentric muscle work can be associated with rhabdomyolysis, supervised eccentric training with gradually increasing loads has important advantages compared with conventional concentric work, particularly for patients with a poor cardiorespiratory system. We report the beneficial effects (particularly, increased VO(2peak) (from 14.6 to 30.8 ml/kg/min) and increased gross muscle efficiency (from 13.8% to 17.2%)) induced by a supervised aerobic training programme of 7 months duration including 3-4 running sessions (< or =60 min/session) per week in a 38-year-old patient. These preliminary data suggest the potential therapeutic value of this type of exercise in these patients.     

Acute adaptation to low volume eccentric exercise.

PURPOSE: Many symptoms of eccentric muscle damage can be substantially reduced if a similar eccentric bout is repeated within several weeks of the initial bout. The purpose of this study was to determine whether a nondamaging, low repetition, low volume eccentric exercise bout could also provide a protective/adaptive effect. METHODS: Subjects were assigned to a control (CON), eccentric exercise (ECC), or low volume familiarized eccentric exercise group (LV+ECC). Before the study, the LV+ECC group performed six maximal eccentric contractions during two familiarization sessions. The main eccentric bout targeted the elbow flexor muscle group and consisted of 36 maximal eccentric contractions. Muscle soreness, upper arm girth, elbow angle, creatine kinase activity, isometric torque, and concentric and eccentric torque at 0.52 and 3.14 rad.s-1 were assessed 0, 1, 2, 3, 4, 7, and 10 d postexercise. RESULTS: No evidence of muscle damage was observed as a result of the low volume eccentric bouts. Nevertheless, with the exception of muscle soreness and concentric torque, all variables recovered more rapidly in the LV+ECC group (P < 0.05). CONCLUSION: Adaptation to eccentric exercise can occur in the absence of significant muscle damage. Exposure to a small number of nondamaging eccentric contractions can significantly improve recovery after a subsequent damaging eccentric bout. Furthermore, this adaptation appears to be mode-specific and not applicable to concentric contractions.     

Eccentric calf muscle training in non-athletic patients with Achilles tendinopathy.

OBJECTIVE: Achilles tendinopathy is prevalent in athletes, but can also affect sedentary patients. We studied the effects of eccentric exercises in sedentary non-athletic patients with Achilles tendinopathy. METHODS: Thirty-four sedentary patients (18 males, average age 44 years, range 23-67; 16 females, average age 51 years, range 20-76; average BMI: 28.6+/-4.7, range 22.1-35.4) with a clinical diagnosis of unilateral tendinopathy of the main body of the Achilles tendon completed the VISA-A questionnaire at first attendance (39+/-S.D. 22.8) and at their subsequent visits. The patients underwent a graded progressive eccentric calf strengthening exercises programme for 12 weeks. RESULTS: Fifteen patients (44%) did not improve with eccentric exercise regimen. Three patients improved after perintendinous injections aprotinin and local anaesthetic. Surgery was performed in seven patients as 6 months of conservative management failed to produce improvements. The overall average VISA-A scores at latest follow up was 50 (S.D. 26.5). CONCLUSIONS: Eccentric exercises, though effective in nearly 60% of our patients, may not benefit sedentary patients to the same extent reported in athletes.     

Lower back and elbow injuries in golf

Golf injuries to the lower back and elbow are common problems in both the professional and amateur player, and any information regarding the successful treatment of these injuries has important implications for the medical practitioner. This paper presents the successful management and outcome of two case studies associated with low back pain and lateral epicondylitis in golf. Exercise therapy and conditioning has been shown to be an effective treatment modality for these two types of injury. In particular, a dynamic exercise programme which incorporates golf functional rehabilitation, is a modern and accepted method by both the patient and the clinician. Effective programmes need to be golf-specific to maintain the interest of the participant and yet at the same time they need to be able to accommodate other factors such as age, gender and the level of the golfer. Furthermore, it is critical that the clinical practitioner has a fundamental knowledge of normal swing mechanics and a working knowledge of the musculoskeletal requirements needed to swing a golf club. In the case of the lower back injury, evaluation was based on detailed computer tomography and centred on the conditioning of the transversus abdominis muscle. Although this muscle is not considered to be paraspinal, it has particularly important implications in the maintenance of spinal stability so that other more specific golf functioning exercises and rehabilitation can be performed. For the case study of lateral epicondylitis detailed evaluation and consideration of neuropathy was an important factor in the diagnostic process. In part, it was necessary to deviate from conventional treatment to produce an effective outcome. A comprehensive resistance-strength-training programme and golf functional 'hitting' programme was used to treat the problem. The conformity by the patient to complete the exercise regimen has been an issue of concern for clinicians managing and treating golf-related problems. Many golfers are 'fanatical' and unless they can see that by continuing the programme their injury will be overcome, it is difficult trying to restrict their time on the golf course. The two case studies described in this article highlight how an extensive and dynamic golf functional programme could be used as an effective method for managing and preventing golf injuries.