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Basics ⬇

Author(s): Emily B.Porter, MD, ATC and Craig C.Young, MD

Description

Medial epicondylitis is clinically defined as pain at the medial epicondyle due to repetitive flexion and pronation at the elbow. A more accurate term may be medial epicondylosis or epicondylalgia. It is usually an overuse injury that can affect both athletes and nonathletes. Golfer’s elbow is a common term used for medial epicondylitis.

Epidemiology

  • Diagnosed less often than lateral epicondylitis, a similar condition affecting the origin of the common extensor tendon on the lateral epicondyle
  • Overall prevalence of <1% in general population but may be as high as 3.8–8.2% in occupational settings (1)[C]
  • Diagnosis is often made in the 4th and 5th decades, although the condition has been seen in patients ranging from 12 to 80 yr of age.
  • Men and women are affected equally.
  • The dominant hand is most often affected.

Etiology and Pathophysiology

  • Initially thought to be an inflammatory process, but histologic studies do not show inflammatory cells in chronic epicondylitis.
  • Inflammation may play a role in the initial acute injury when microtearing of the tendon occurs.
  • Histologic studies of chronic epicondylitis have shown abnormal collagen architecture due to a fibroblastic and immature vascular response, which causes incomplete tendon repair.
  • Degenerative changes often seen in the pronator teres and flexor carpi radialis muscles and their tendons:
    • Palmaris longus, flexor digitorum superficialis, and flexor carpi ulnaris may also be involved.
  • Common causes:
    • Activities that involve forceful and/or continuous wrist flexion and/or forearm pronation or a large amount of stabilization—especially with forearm supinated (2)[B], such as racquet sports, swimming, swinging a golf club, throwing, playing tennis, waterskiing, using a computer keyboard, or playing piano
    • Certain occupations (carpenters, plumbers, meat cutters, etc.) may be more at risk.

Diagnosis ⬆ ⬇

History

  • Pain and tenderness along the medial elbow, extending into the forearm, which worsen with resisted forearm pronation or wrist flexion at 90 degrees of elbow flexion and/or full elbow extension
  • Difficulty gripping without pain
  • Decreased wrist strength
  • Tightness/stiffness when stretching elbow and wrist

Physical Exam

  • Tenderness to palpation over the medial epicondyle, pronator teres, and flexor carpi radialis
  • Local swelling and warmth may be present.
  • Active and resisted range of motion may be full or limited depending on the severity of the injury.

Differential Diagnosis

  • Entrapment neuropathy (i.e., cubital tunnel syndrome, carpal tunnel syndrome)
  • Ulnar neuritis
  • Ulnar collateral ligament (UCL) insufficiency
  • Medial elbow apophysitis (i.e., “Little Leaguer’s elbow”)
  • Inflammatory arthritis
  • Cervical radiculopathy
  • Thoracic outlet syndrome
  • Myofascial pain

Diagnostic Tests & Interpretation

  • Generally not needed for initial evaluation
  • In cases that are refractory to treatment or where the diagnosis is in question, basic elbow x-rays followed by ultrasound (US) or magnetic resonance imaging (MRI) may be considered.

Treatment ⬆ ⬇

  • More studies are needed specifically on medial epicondylitis; most studies focus on treatment of lateral epicondylitis. Many of these treatments are used for medial epicondylitis as well.
  • Initial treatment includes relative rest, ice, and acetaminophen or over-the-counter (OTC) nonsteroidal anti-inflammatory drugs (NSAIDs) as needed.
  • The mainstay of treatment involves stretching and strengthening with progression to eccentric training exercise with or without formal physical therapy (3)[A].
  • Bracing may be helpful.
  • If no improvement in 6 wk, consider obtaining x-rays and initiating formal physical therapy.
  • If still symptomatic, consider injection. Various techniques have been proposed, including dry needling of tendon, corticosteroid injection, or use of newer techniques, including prolotherapy or injection of platelet-rich plasma or autologous blood (4)[A].
  • Other treatments to consider include nitric oxide via topical nitroglycerin, extracorporeal shock wave therapy, or percutaneous ultrasonic tenotomy performed under local anesthesia (4,5)[A],(6)[B].
  • If symptoms persist, consider advanced imaging with US or MRI to confirm diagnosis.
  • Rarely, recalcitrant symptoms >6 mo in duration may require surgical intervention.

Ongoing Care ⬆ ⬇

Home exercise program as follows:

  • Strengthening:
    • Stay below the level of pain.
    • Perform two to three sets of 10 to 15 repetitions 2 to 4 times a week. Once three sets of 15 repetitions can be performed easily, increase the weight, reduce the repetitions to 10, and build back up to 15.
    • Wrist extension curls: With the forearm supported on a firm surface and the palm facing downward, lift and lower the weight.
    • Wrist flexion curls: With the forearm supported on a firm surface and the palm facing upward, lift and lower the weight.
    • Forearm pronation/supination: With the forearm supported on a firm surface, turn the palm up and then down while holding onto a weight.
    • Gripping: Gently grip a rubber ball, a towel, or putty and then advance to items with more resistance. Perform 10 to 30 repetitions, increasing in intensity once 30 repetitions can be performed.
    • Finger extension: Wrap a rubber band around the outside of all the fingers and thumb, gently extend the hand by opening the fingers, and then close the fingers. Perform 10 to 30 repetitions.
  • Stretching:
    • Keep the stretch to a comfortable level.
    • Hold each stretch for ~30 sec.
    • Repeat each stretch 3 to 6 times.
    • Wrist flexion stretch: Bend the involved wrist down gently by grasping it with the other hand until a pulling sensation is felt. Keep the elbow straight.
    • Wrist flexion stretch (advanced): same as for the wrist flexion stretch but with the addition of wrist movement toward the side of the little finger
    • Wrist extension stretch: Bend the involved wrist up gently by grasping it with the opposite hand until a pulling sensation is felt. Keep the elbow straight.

Additional Reading ⬆ ⬇

  • Gündüz R, Malas FÜ, Borman P, et al. Physical therapy, corticosteroid injection, and extracorporeal shock wave treatment in lateral epicondylitis. Clinical and ultrasonographical comparison. Clin Rheumatol. 2012;31(5):807–812.
  • Han SH, Lee JK, Kim HJ, et al. The result of surgical treatment of medial epicondylitis: analysis with more than a 5-year follow-up. J Shoulder Elbow Surg. 2016;25(10):1704–1709.
  • Paoloni JA, Appleyard RC, Nelson J, et al. Topical nitric oxide application in the treatment of chronic extensor tendinosis at the elbow: a randomized, double-blinded, placebo-controlled clinical trial. Am J Sports Med. 2003;31(6):915–920.
  • Stasinopoulos D, Stasinopoulos I. Comparison of effects of eccentric training, eccentric-concentric training, and eccentric-concentric training combined with isometric contraction in the treatment of lateral elbow tendinopathy. J Hand Ther. 2017;30(1):13–19.
  • Suresh SP, Ali KE, Jones H, et al. Medial epicondylitis: is ultrasound guided autologous blood injection an effective treatment?Br J Sports Med. 2006;40(11):935–939.
  • Thiese MS, Hegmann KT, Kapellusch J, et al. Psychosocial factors related to lateral and medial epicondylitis: results from pooled study analyses. J Occup Environ Med. 2016;58(6):588–593.

References ⬆ ⬇

  1. Amin NH, Kumar NS, Schickendantz MS. Medial epicondylitis: evaluation and management. J Am Acad Orthop Surg. 2015;23(6):348–355.
  2. Rosa D, Di Donato SL, Balato G, et al. Supinated forearm is correlated with the onset of medial epicondylitis in professional slalom water-skiers. Muscles Ligaments Tendons J. 2016;6(1):140–146.
  3. Hoogvliet P, Randsdorp MS, Dingemanse R, et al. Does effectiveness of exercise therapy and mobilisation techniques offer guidance for the treatment of lateral and medial epicondylitis?A systematic review. Br J Sports Med. 2013;47(17):1112–1119.
  4. Hussain N, Johal H, Bhandari M. An evidence-based evaluation on the use of platelet rich plasma in orthopedics—a review of the literature. SICOT J. 2017;3:57.
  5. Gambito ED, Gonzalez-Suarez CB, Oquiñena TI, et al. Evidence on the effectiveness of topical nitroglycerin in the treatment of tendinopathies: a systematic review and meta-analysis. Arch Phys Med Rehabil. 2010;91(8):1291–1305.
  6. Barnes DE, Beckley JM, Smith J. Percutaneous ultrasonic tenotomy for chronic elbow tendinosis: a prospective study. J Shoulder Elbow Surg. 2015;24(1):67–73.

Clinical Pearls ⬆

  • Wrist splints are often more helpful than counterforce bracing if the patient has significant pain upon awakening. However, counterforce braces are often better tolerated during the day.
  • The cost of nitroglycerin patches can be decreased by cutting them in half or quarters.