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ESSENTIAL SKILLS times before tiring. Her injured arm could not lift even 1 pound without discomfort. The fl exibility of both wrists was limited to 75 degrees. (A healthy wrist easily moves to 90 degrees of extension and fl exion.) This is a case of an injury just waiting to happen. Our goal now is to build up fl exibility and enough strength in her fl exors and extensors that she can easily exercise with 10 pounds with her good arm, and eventually (after six to eight weeks of treatment) with her injured arm as well. INJURY VERIFICATION— RESISTED FLEXION OF WRIST Ask the client to hold the injured arm out in front of the body and fl ex the hand down toward the fl oor (Image 1). Place one of your hands on top of the wrist to support it, and wrap the fi ngers of your other hand around the client's palm. Now, ask the client to hold the hand in this position while you try to pull it forward and up. Hold this isometric position for a few seconds. For a person with golfer's elbow, this action will cause pain at the medial elbow and/or into the forearm. TREATMENT CHOICES SELF-TREATMENT If this injury is recent, it will usually respond well to rest combined with wrist fl exion exercises with light weights (which should begin a few weeks into the recovery period). For the full exercise protocol, see the exercise section below. FRICTION THERAPY AND DEEP MASSAGE A combination of these two treatments is generally very effective within four to six weeks. The muscle- tendon unit is easily accessible. To perform the friction, it's best to have the client's elbow bent at a 90-degree angle and the forearm slightly supinated. Place the tip of your thumb at the edge of the fl exor carpi radialis tendon, just inferior to and up against the edge of the medial epicondyle; this is the tenoperiosteal junction. Now press laterally against the bone to compress the tendon, and friction in a medial direction (Image 2). Continue for fi ve or six minutes, take a break, and repeat, for a total of 10–12 minutes of frictioning. Then massage the upper arm and forearm to maximize blood circulation to the tendon. An important caution when working in this area: the fl exor carpi radialis is near the ulnar nerve. If your client feels tingling or electric sensations down the arm, that means you've hit the nerve and you need to shift where you're working. EXERCISE Following an exercise program is an important part of recovery from golfer's elbow. The program I'll describe here, based on a basic protocol developed by William D. Stanish and Sandra Curwin in the 1980s, is specifi cally designed to support the healing of tendon injuries. I have used this program for more than 20 years and have found it to be very useful in helping clients heal more quickly and effectively. It gives clients an opportunity to take 108 massage & bodywork march/april 2009 an active part in their recovery, while strengthening the weakened muscle and tendon tissues and helping prevent the reformation of adhesive scar tissue. This program must be done every day, seven days a week, or it may not work. It is usually done once a day at fi rst, but should be done twice a day after about two weeks. It's important to continue the program for six to eight weeks; it takes six times longer to strengthen a tendon than it does to strengthen a muscle. Give your client the following instructions: 1. Warm up Wave your hand up and down, as if you were saying goodbye, for two to three minutes. 2. Stretch Stand beside a table and rest the palm of your hand on the table with your elbow straight. Keeping the hand relaxed, apply a downward force until you feel a stretch through the forearm (Image 3). Do this fi ve times, maintaining the stretch for 20–30 seconds each time and resting for a moment between stretches. 3. Exercise Extend the injured arm in front of you, with the palm facing the ceiling, and use your other hand to support the elbow. Then, holding a 1- or 2-pound weight, curl the hand up in fl exion and then slowly lower it to the starting