Physical Medicine and Rehabilitation for Epicondylitis Clinical Presentation

  • Author: Sharon J Gibbs, MD; Chief Editor: Rene Cailliet, MD   more...
 
Updated: Jan 18, 2012
 

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 at Texas Back Institute

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

Disclosure: emedicine Honoraria Other

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 and Texas Medical Association

Disclosure: Nothing to disclose.

Specialty Editor Board

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, American Association of Neuromuscular and Electrodiagnostic Medicine, American Paraplegia Society, Association of Academic Physiatrists, National Multiple Sclerosis Society, and Physiatric Association of Spine, Sports and Occupational Rehabilitation

Disclosure: Nothing to disclose.

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

Disclosure: Medscape Salary Employment

Patrick M Foye, MD  Associate Professor of Physical Medicine and Rehabilitation, Co-Director of Musculoskeletal Fellowship, Co-Director of Back Pain Clinic, Director of Coccyx Pain Service (Tailbone Pain Service: www.TailboneDoctor.com), University of Medicine and Dentistry of New Jersey, New Jersey Medical School

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

Disclosure: Nothing to disclose.

Kelly L Allen, MD  Medical Director, Medevals

Disclosure: Nothing to disclose.

Chief Editor

Rene Cailliet, MD  Professor-Chairman Emeritus, Department of Rehabilitation Medicine, University of Southern California School of Medicine; Former Director, Department of Rehabilitation Medicine, Santa Monica Hospital Medical Center

Rene Cailliet, MD is a member of the following medical societies: American Academy of Pain Medicine, American Academy of Physical Medicine and Rehabilitation, American Pain Society, Association of American Medical Colleges, International Association for the Study of Pain, and Pan American Medical Association

Disclosure: Nothing to disclose.

References

  1. Rineer CA, Ruch DS. Elbow tendinopathy and tendon ruptures: epicondylitis, biceps and triceps ruptures. J Hand Surg Am. Mar 2009;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. Apr 2008;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). May 2009;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. Feb 2009;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. Jul-Aug 2005;34(4):127-42. [Medline].

  6. Park GY, Lee SM, Lee MY. Diagnostic value of ultrasonography for clinical medial epicondylitis. Arch Phys Med Rehabil. Apr 2008;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. Gabel GT, Morrey BF. Operative treatment of medical epicondylitis. Influence of concomitant ulnar neuropathy at the elbow. J Bone Joint Surg Am. Jul 1995;77(7):1065-9. [Medline].

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

  10. Carson WG. Overuse injuries of the elbow in the throwing athlete. In: Baker CL, ed. The Hughston Clinic Sports Medicine Book. Baltimore, Md: Williams & Wilkins; 1995:324-31.

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

  12. Gabel GT, Morrey BF. Medial epicondylitis. In: Morrey BF, ed. The Elbow and Its Disorders. 3rd ed. Philadelphia, Pa: WB Saunders; 2000:537-42.

  13. Kraushaar BS, Nirschl RP. Tendinosis of the elbow (tennis elbow). Clinical features and findings of histological, immunohistochemical, and electron microscopy studies. J Bone Joint Surg Am. Feb 1999;81(2):259-78. [Medline].

  14. Ollivierre CO, Nirschl RP, Pettrone FA. Resection and repair for medial tennis elbow. A prospective analysis. Am J Sports Med. Mar-Apr 1995;23(2):214-21. [Medline].

  15. Stahl S, Kaufman T. The efficacy of an injection of steroids for medial epicondylitis. A prospective study of sixty elbows. J Bone Joint Surg Am. Nov 1997;79(11):1648-52. [Medline].

  16. Stahl S, Kaufman T. Ulnar nerve injury at the elbow after steroid injection for medial epicondylitis. J Hand Surg [Br]. Feb 1997;22(1):69-70. [Medline].

  17. Vangsness CT Jr, Jobe FW. Surgical treatment of medial epicondylitis. Results in 35 elbows. J Bone Joint Surg Br. May 1991;73(3):409-11. [Medline]. [Full Text].

 
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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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