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Physical Medicine and Rehabilitation for Epicondylitis Clinical Presentation

  • Author: Sharon J Gibbs, MD; Chief Editor: Stephen Kishner, MD, MHA  more...
 
Updated: Apr 20, 2016
 

History

ME is characterized by pain over the medial epicondyle. Pain worsens with wrist flexion and forearm pronation activities. Patients may report discomfort even when simply shaking hands with someone. Up to 50% of patients with ME complain of occasional or constant numbness and/or tingling sensation that radiates into their fourth and fifth fingers, suggesting involvement of the ulnar nerve.

The patient's history may include the occurrence of an acute injury as a result, for instance, of taking a divot in golf, throwing a pitch in baseball, or hitting a hard serve in tennis.

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Physical

Tenderness with palpation over the anterior aspect of the medial epicondyle is the most consistent finding. Other characteristics of ME include the following:

  • Typically, pain is reproduced with resisted wrist flexion or resisted forearm pronation.
  • Occasionally, the area of tenderness extends approximately 1 inch toward the proximal flexor-pronator muscle mass just distal to the epicondyle.
  • The range of motion of the elbow and wrist is usually within normal limits.
  • Patients may have symptoms of an ulnar neuropathy (eg, decreased sensation in the ulnar nerve distribution, a positive elbow-flexion test, a positive Tinel sign). In more severe cases, decreased sensation is associated with intrinsic weakness; intrinsic muscle atrophy may be noted.
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Causes

The causes of ME include the following:

  • The condition can result from the repetitive use of flexor-pronator muscles, especially with valgus stress at the medial epicondyle.
  • The onset can be related to the patient's occupation (if, for example, his/her job requires repetitive actions, such as the consistent use of a screwdriver or hammer).[3]
  • ME's onset can accompany acute injury.
  • An excessive topspin in tennis, excessive grip tension, improper pitching techniques in baseball, and an improper golf swing[4] are common sports-related causes of ME.
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Contributor Information and Disclosures
Author

Sharon J Gibbs, MD Physiatrist, Multidisciplinary Spine Practice, Texas Back Institute

Sharon J Gibbs, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, Physiatric Association of Spine, Sports and Occupational Rehabilitation, International Spine Intervention Society, Texas Medical Association

Disclosure: Nothing to disclose.

Coauthor(s)

Kenneth S Dauber, MD, PA Consulting Staff, Department of Physical Medicine and Rehabilitation, Plano Orthopedic and Sports Medicine Center

Kenneth S Dauber, MD, PA is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, Texas Medical Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Patrick M Foye, MD Director of Coccyx Pain Center, Professor and Interim Chair of Physical Medicine and Rehabilitation, Rutgers New Jersey Medical School; Co-Director of Musculoskeletal Fellowship, Co-Director of Back Pain Clinic, University Hospital

Patrick M Foye, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, International Spine Intervention Society, American Association of Neuromuscular and Electrodiagnostic Medicine, Association of Academic Physiatrists

Disclosure: Nothing to disclose.

Chief Editor

Stephen Kishner, MD, MHA Professor of Clinical Medicine, Physical Medicine and Rehabilitation Residency Program Director, Louisiana State University School of Medicine in New Orleans

Stephen Kishner, MD, MHA is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, American Association of Neuromuscular and Electrodiagnostic Medicine

Disclosure: Nothing to disclose.

Additional Contributors

Daniel D Scott, MD, MA Associate Professor, Department of Physical Medicine and Rehabilitation, University of Colorado School of Medicine; Attending Physician, Department of Physical Medicine and Rehabilitation, Denver Veterans Affairs Medical Center, Eastern Colorado Health Care System

Daniel D Scott, MD, MA is a member of the following medical societies: Alpha Omega Alpha, American Academy of Physical Medicine and Rehabilitation, Academy of Spinal Cord Injury Professionals, National Multiple Sclerosis Society, Physiatric Association of Spine, Sports and Occupational Rehabilitation, American Association of Neuromuscular and Electrodiagnostic Medicine, Association of Academic Physiatrists

Disclosure: Nothing to disclose.

References
  1. Rineer CA, Ruch DS. Elbow tendinopathy and tendon ruptures: epicondylitis, biceps and triceps ruptures. J Hand Surg Am. 2009 Mar. 34(3):566-76. [Medline].

  2. Budoff JE, Hicks JM, Ayala G, et al. The reliability of the "scratch test". J Hand Surg Eur Vol. 2008 Apr. 33(2):166-9. [Medline].

  3. van Rijn RM, Huisstede BM, Koes BW, et al. Associations between work-related factors and specific disorders at the elbow: a systematic literature review. Rheumatology (Oxford). 2009 May. 48(5):528-36. [Medline].

  4. Farber AJ, Smith JS, Kvitne RS, et al. Electromyographic analysis of forearm muscles in professional and amateur golfers. Am J Sports Med. 2009 Feb. 37(2):396-401. [Medline].

  5. Banks KP, Ly JQ, Beall DP, et al. Overuse injuries of the upper extremity in the competitive athlete: magnetic resonance imaging findings associated with repetitive trauma. Curr Probl Diagn Radiol. 2005 Jul-Aug. 34(4):127-42. [Medline].

  6. Park GY, Lee SM, Lee MY. Diagnostic value of ultrasonography for clinical medial epicondylitis. Arch Phys Med Rehabil. 2008 Apr. 89(4):738-42. [Medline].

  7. Krischek O, Hopf C, Nafe B, et al. Shock-wave therapy for tennis and golfer's elbow--1 year follow-up. Arch Orthop Trauma Surg. 1999. 119(1-2):62-6. [Medline].

  8. Beyazal MS, Devrimsel G. Comparison of the effectiveness of local corticosteroid injection and extracorporeal shock wave therapy in patients with lateral epicondylitis. J Phys Ther Sci. 2015 Dec. 27 (12):3755-8. [Medline].

  9. Gabel GT, Morrey BF. Operative treatment of medical epicondylitis. Influence of concomitant ulnar neuropathy at the elbow. J Bone Joint Surg Am. 1995 Jul. 77(7):1065-9. [Medline].

  10. Shahid M, Wu F, Deshmukh SC. Operative treatment improves patient function in recalcitrant medial epicondylitis. Ann R Coll Surg Engl. 2013 Oct. 95(7):486-8. [Medline].

  11. Kwon BC, Kwon YS, Bae KJ. The Fascial Elevation and Tendon Origin Resection Technique for the Treatment of Chronic Recalcitrant Medial Epicondylitis. Am J Sports Med. 2014 Apr 23. 42(7):1731-1737. [Medline].

  12. Stefanou A, Marshall N, Holdan W, Siddiqui A. A randomized study comparing corticosteroid injection to corticosteroid iontophoresis for lateral epicondylitis. J Hand Surg Am. 2012 Jan. 37(1):104-9. [Medline].

  13. Ciccotti MG, Ramani MN. Medial epicondylitis. Tech Hand Up Extrem Surg. 2003 Dec. 7(4):190-6. [Medline].

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Medial epicondyle.
Strengthening exercises are performed once pain has subsided with active range of motion. The starting position (slight pronation) of an eccentric exercise for medial epicondylitis is shown. In order to prevent further injury, a trained therapist should instruct patients in exercises to confirm proper weight and technique. (The X indicates the medial epicondyle).
The eccentric exercise proceeds until full supination has been reached.
 
 
 
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